Highmark Commercial Medical Policy - Pennsylvania
Medical Policy: L-27-016
Topic: Organ or Disease Oriented Panels
Section: Laboratory
Effective Date: January 1, 2016
Issue Date: January 4, 2016
Last Reviewed: November 2015

Certain ranges of procedure codes represent organ or disease oriented panels. These panels combine certain laboratory tests under a specific problem-oriented classification.

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.

Procedure codes 80048-80090 represent organ or disease oriented panels. When performed for asymptomatic patients, organ or disease oriented panels are considered screening and are only covered by certain groups or programs as indicated in benefits.

Many of the disease-oriented panel tests on the table attachment are covered. The component tests for each covered panel are listed. These are the minimum tests that must be performed before a disease-oriented panel code can be reported.

If less than the minimum tests are performed, payment should be made for the individual tests.

Procedure Codes
80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076, 80081


See Medical Policy Bulletin L-29 for information regarding evocative/suppression testing panels. 

See attachment for information on organ or disease oriented panels.



The policy position applies to all commercial lines of business


FEP Guidelines

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.


Denial Statements

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

Links




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 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.