| Highmark Commercial Medical Policy - Pennsylvania |
| 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.
Experimental/Investigational
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:
Not Medically Necessary
The following services are considered not medically necessary:
Program Exclusion/Not a Benefit
The following services are considered a program exclusion/not a benefit, and therefore non-covered:
No Professional Service Rendered
The following services are considered no professional service rendered, and therefore non-covered:
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.
| Links |
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.
