Highmark Commercial Medical Policy - Pennsylvania

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Medical Policy: Z-24-098
Topic: Miscellaneous Services
Section: Miscellaneous
Effective Date: May 14, 2018
Issue Date: May 14, 2018
Last Reviewed: September 2017

This policy addresses those services considered to be miscellaneous and are typically not covered services.

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.

Policy Position Coverage is subject to the specific terms of the member’s benefit plan.

ALL services on this policy are non-covered for ONE of the following reasons:

·         The service is considered experimental/investigational;

o    Experimental/investigational services are defined as a treatment, procedure, facility, equipment, drug, service or supply (intervention) that has been determined not to be medically effective for the condition being treated.  These determinations are based on one or more of the following reasons:

§  The intervention does not have FDA approval to be marketed for the specific relevant indication(s); or

§  Available scientific evidence does not permit conclusions concerning the effect of the intervention on health outcomes; or

§  The intervention is not proven to be as safe or effective in achieving an outcome equal to or exceeding the outcome of alternative therapies; or

§  The intervention does not improve health outcomes; or

§  The intervention is not proven to be applicable outside the research setting; or


·         The service is considered not medically necessary because it does not  meet the definition of medically necessary;

o    Medically Necessary or Medical Necessity is defined as health care services or supplies that a provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms, and that are:

§  In accordance with generally accepted standards of medical practice; and

§  Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's illness, injury or disease; and

§  Not primarily for the convenience of the patient or the provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.

o    For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, Specialty Society recommendations, and the views of providers practicing in relevant clinical areas and any other relevant factors; or 


·         The service is a program exclusion/not a benefit:

o    Services generally not covered under the specified program(s);or

o    Groups define benefits, and determine coverage; or


·         No professional service has been rendered;

o    The service does not require direct patient care or contact.


The following services are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature:

  • Adoptive Immunotherapy
  • Anal fistula plug
  • Bioimpedance spectroscopy for lymphedema
  • Carbon monoxide, expired gas analysis (e.g., ETCO/hemolysis breath test)
  • Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) (ImmuKnow®)
  • Electromagnetic Navigational Bronchoscopy (ENB) (e.g., SuperDimension Bronchus System, inReachTM System, iLogicTM Electromagnetic Navigation BronchoscopyTM, ig4TM EndoBronchial System )
  • Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
  • Endoscopic CryoSpray ablation of the esophagus
  • Ferriscan
  • ImPACT Concussion Testing
  • Multivariate analysis of patient-specific findings with quantifiable computer probability assessment, including report
  • Neuro-selective current perception threshold (CPT)/Sensory Nerve Conduction Test
  • My5-FU™ Genetic test designed to measure colorectal cancer patient's exposure to 5-FU to help oncologists adjust and optimize 5-FU dosing and improve patient outcomes
  • Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or arterial, venous, or capillary glucose; and/or potassium concentration
  • Per-oral Endoscopic Myotomy (POEM) for treatment of esophageal achalasia
  • pH; exhaled breath condensate
  • Posturography (dynamic or static)
  • PreDx (Diabetes Risk Score)
  • Saliva test, hormone level; to assess preterm labor
  • Saliva test, hormone level; during menopause
  • Tenotomy of elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow; percutaneous)
  • Thromboxane metabolite(s), including thromboxane if performed, urine
  • Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
  • InfraScanner Handheld Brain Hematoma Screening System For Early Detection of Intracranial Hemorrhage (ICH)
Procedure Codes
24357, 29999, 31627, 43499, 46707, 53860, 76498, 81506, 83987, 84431, 84999, 86352, 92548, 93702, 96116, 96118, 96119, 96120, 99199, G0255, G9147, S2107, S2300, S3650, S3652, S3722

Not Medically Necessary

The following services are considered not medically necessary:

  • Defecography
  • Grenz Ray Therapy
  • Hair analysis
  • Lixiscope Service
  • Rhinomanometry
Procedure Codes
92512, P2031

Program Exclusion/Not a Benefit

The following services are considered a program exclusion/not a benefit, and therefore non-covered:

  • Casted impressions for special shoes
  • EROS-Clitoral Therapy Device as a treatment of female sexual dysfunction
  • Hearing aid evaluation
  • Recreational or educational therapy (inpatient)
Procedure Codes
92590, 92591, 92592, 92593, 92594, 92595, A9270, S0395

No Professional Service Rendered 

The following services are considered no professional service rendered, and therefore non-covered:

  • Broken appointments
  • Glucola (glucose preparation)
  • Mileage for medical visit
  • Prolonged physician services without direct (face-to-face) contact
  • Team conferences
  • Telephone calls
  • Treatment planning and care coordination management for cancer initial treatment
  • Treatment planning and care coordination management for cancer established patient with a change of regimen
Procedure Codes
98966, 98967, 98968, 99358, 99359, 99366, 99367, 99368, 99441, 99442, 99443, 99446, 99447, 99448, 99449, A9270, S0353, S0354

Refer to medical policy Z-67, Experimental/Investigational Services for additional information.

Refer to medical policy Z-11, Definition of Medical Necessity, for additional information.

Refer to medical policy G-27, Clinical Trials, for additional information.

Place of Service: Outpatient

Experimental/Investigational (E/I) services are not covered regardless of place of service.

A miscellaneous service 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.

The policy position applies to all commercial lines of business

Denial Statements

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.

A network provider can bill the member for the non-covered service.


  • Link to Provider Resource Center for the Medical Policy Update
  • 05/2015, InfraScanner Handheld Brain Hematoma Screening System for Early Detection of Intracranial Hemorrhage (ICH) Considered Experimental-Investigational
    03/2015, Ablation procedures for peripheral neuromas considered experimental/investigational.

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:
  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages
If you need these services, contact the Civil Rights Coordinator.

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.

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