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.
M0100 Intragastric hypothermia using gastric freezing
M0301 Fabric wrapping of abdominal aneurysm
P2028 Cephalin flocculation, blood
P2029 Congo red, blood
P2031 Hair analysis (excluding arsenic)
P2033 Thymol turbidity, blood
P2038 Mucoprotein, blood (seromucoid)
S1030 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)
S1031 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)
S2103 Adrenal tissue transplant to brain
S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy
S9001 Home uterine monitor with or without associated nursing services
Policy: 12.01.01av:Experimental/Investigational Services