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Medical Policy Updates
Notification of Policy Revisions Effective July 1, 2004
(Posted April 22,2004)
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Revision |
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Bundling Guidelines
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Effective date 7/01/04. Revisions under the "Topic of Frequent Interest" section of the policy, Flouroscopic Guidance "Fluoroscopic Guidance- In general, fluoroscopic guidance is considered incidental to the procedure being done. However, code 76005 will be allowed separately when reported with 27096, 62270-62282, 62310-62319, 64470-64484, 64622-64627. 76005 will be considered incidental to 72275 - Epidurography, radiological supervision and interpretation." Ear Wax Removal- Ear wax removal (69210 and G0268) is considered incidental to medical or surgical services. Separate reimbursement is not provided for ear wax removal.
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Breast Surgeries
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Effective date 7/1/04. Changes made for Section III-Reduction Mammaplasty: "When covered", E. criteria revised "The weight of breast tissue to be removed or removed must be greater than the threshold value for a given BSA in order to be considered medically necessary." Also added body surface area formula. Under "Policy Guidelines", added Table 1: Schnur Sliding Scale. Reference sources added.
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Glaucoma, Evaluation by Ophthalmologic Techniques
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Effective date 7/1/04. Specialty Matched Consultant Advisory Panel review 3/24/2003. "Description of Procedure" section revised to clarify techniques to evaluate the retinal nerve fiber layer. Benefits Application and Billing/Coding sections revised. Specialty Matched Consultant review 2/ 19/04. "Policy, "When covered" and "When not covered" sections revised based on specialty matched consultant review. Policy name changed from "Glaucoma, Evaluation by Ophthalmic Techniques" to Glaucoma, Evaluation by Ophthalmologic Techniques".
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Surgery for Morbid Obesity
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Effective date 7/1/04. Under "Description of Procedure" reversed position of malabsorptive procedures and gastric restrictive procedures. Under "When Covered" the following changes were made: A.1.a. - deleted "at least 100% overweight". Policy is referencing BMI rather than weight. A.1.b.v. - added "(e.g. requiring prescription drug treatment)". A.2 changed to "Morbid obesity (BMI > 35 associated with at least one of the problems listed in A.1.b. or BMI > 40) has been present for four of the previous five years." A.4. - added "(for adolescents-bone age shows closure of epiphyseal plates)". A.5. - added "(see Policy Guidelines section)". Under "Policy Guidelines" the following changes were made: In second sentence, "adequate" changed to "thorough". Number 4, Psychological assessment - changed wording following "to include" to "assessment of any diagnosable mental health conditions that may affect treatment, readiness and ability to adhere to required lifestyle modifications and follow up/social support". Following numbers 1) through 6) added "The first four criteria above must be met before seeking prior plan approval, the last two criteria must be met prior to surgery." Benefits Application and Billing/Coding sections revised. CPT code 43659 added to Billing/Coding section as this code may be billed for the Mini-Gastric Bypass procedure. Also added HCPCS codes S2082 and S2085.
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