|Highmark Commercial Medical Policy - Pennsylvania|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Use for Walking in Patients with Spinal Cord Injury (SCI)
A functional electrical stimulator (FES) for SCI (e.g, Parastep® Ambulation System) may be considered medically necessary for individuals with a diagnosis of paraplegia and who meet ALL of the following criteria:
In addition to meeting the above criteria, individuals with SCI must have completed a training program which consists of physical medicine sessions with the device, (Parastep® Ambulation System) over a period of three (3) months. The trial period will enable the physician treating the individual for his or her SCI to properly evaluate the person's ability to use these devices frequently and for the long term. These physical medicine sessions are only covered in the following settings: inpatient hospital, outpatient hospital, comprehensive outpatient rehabilitation facilities, and outpatient rehabilitation facilities. The physical medicine necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program; this service cannot be done unattended.
The goal of physical medicine must be to train SCI patients on the use of the FES device to achieve walking, not to reverse or retard muscle atrophy.
FES for SCI patients is considered not medically necessary and, therefore, not covered for individuals with ANY ONE of the following absolute contraindications:
FES is considered experimental/investigational for all FES devices except for the Parastep System; scientific evidence does not demonstrate the efficacy of other systems.
Coverage is subject to any applicable physical medicine and/or durable medical equipment (DME) limitation in the member's benefit contract.
Treatment of Muscle Atrophy
Functional neuromuscular electrical stimulation (NMES) may be considered medically necessary for treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse are causing atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins).
Supplies for NMES may be considered medically necessary when annual documentation is noted in the patient’s medical record.
Experimental/Investigational (E/I) services are not covered regardless of place of service.
NMES is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Services that do not meet the criteria of this policy will be considered experimental/investigational (E/I). A network provider can bill the member for the experimental/investigational service. The provider must give advance written notice informing the member that the service has been deemed E/I. The member must be provided with an estimate of the cost and the member must agree in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.