|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.
For the treatment of Actinic Keratosis (AK) ANY of the following treatments may be considered medically necessary:
Epidermal/superficial chemical peels or superficial dermabrasion for the treatment of actinic keratosis is considered cosmetic and therefore, non-covered.
AK treatments for any other indication is considered cosmetic and, therefore, non-covered.
Chemo surgical Destruction
Chemo surgical destruction with (Fluorouracil) 5 FU or treatment with 5 FU of actinic keratosis is considered an integral part of a doctor's medical care and is not eligible as a distinct and separate service. The physician does not personally remove the keratosis but gives the patient medication to apply daily under his supervision. If chemo surgical destruction with 5 FU is reported on the same day as a doctor's medical care, and the charges are itemized, combine the charges and pay only the doctor's medical care. Payment for the doctor's medical care performed on the same date of service includes the allowance for the chemo surgical destruction with 5 FU. A network provider cannot bill the member for chemo surgical destruction with 5 FU in this case.
If the chemo surgical destruction with 5 FU is performed independently, process it under the appropriate code(s).
Modifier 25 may be reported with medical care to identify it as a significant, separately identifiable service from the application of 5 FU. When the 25 modifier is reported, the patient’s records must clearly document that separately identifiable medical care has been rendered.
Refer to medical policy S-71 Photodynamic Therapy, (PDT) using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA] or Metvixa® (Methyl Aminolevulinate) for additional information.
Refer to medical policy S-28 Cosmetic Surgery vs. Reconstructive Surgery for additional information.
Actinic Keratosis 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.
A network provider can bill the member for the cosmetic service.
A network provider cannot bill the member for the non-covered service.
03/2015, Facility Now Applicable to Actinic Keratosis
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.