Note (06/11/2020): This version of the policy is on hold and will not become effective on 06/15/2020 as previously communicated. The newly added codes communicated in this version will not require precertification at this time. The Company will communicate status updates in the future.
This version of the policy will become effective on 06/15/2020.
Several procedure codes and services represented by them are being added to this program of utilization management activities by AIM as follows:
Procedure Codes 20939, 20974, 22532, 22548, 22556, 22590, 22595, 22857, 63003, 63016, 63046, 63055, 63180, 63182, 63185, 63190, 63191, 63194, 63196, 63198, 63200, 63250, 63252, 63265, 63267, 63270, 63272, 63275, 63277, 63280, 63282, 63285, 63287, 63290, 0163T, 0164T, 0165T, 0375T, C9359 and C9362 are added to Attachment A of the policy.
Procedure codes 23700, 27120, 27122, 27437, 27445, 27488, 28446, 29871, 29892, G0289 and G0428 are added to Attachment B of the policy.
Procedure codes 64640, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T, C1767, C1820, C1822, L8679, L8680, L8682, L8683, L8685, L8686, L8687 and L8688 are added to Attachment C of the policy.
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Subject to the terms and conditions of the applicable benefit contract, spinal surgical procedures, joint surgical procedures, and interventional pain management procedures are covered under the medical benefits of the Company’s products when the medical necessity criteria for the services are met.
The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.
In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.
The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.