For your privacy and protection, when applying to a job online, never give your social security number to a prospective employer, provide credit card or bank account information, or perform any sort of monetary transaction. If you require special assistance, including accommodations for disabilities or limited English proficiency, please call us at 1-800-876-7639 or TTY at #711 to receive assistance free of charge. Medical decision making 15.2 ! This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Paper claim forms must be submitted on original red claim forms. Rosacea Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use. Gynecomastia in individuals less than 16 years of age generally will resolve on its own. stains on the face and neck. purposes. Medical Policy Frequently Asked Questions (FAQs). Name of the subscriber - the individual under whose name the coverage d[1X?*=PQ_?' Bilateral procedures performed on different dates of service require the submission of medical record documentation to support the medical necessity of performing these procedures on different dates of service. If that information is not available, call Highmark Blue Shield 's Customer Service at 1-866-731-8080. ),@Km*3kludCzjFke|0Z Q46-QO*zxt0]f!`HwYtJ`j|}Eg3tV[\92B$$DS,m}2Qxul*2Bl)HX. dermabrasion, chemical peels, surgical debulking, and electrosurgery] may be listed procedure below, the procedure may be classified as reconstructive only HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA. Normal range or no hearing loss = 0dB to 20dB.). Speak to a Medicare Advisor To speak with a Medicare Advisor, please call: 1-844-593-0265 Request a Call Have a Highmark Medicare Advisor call you to answer your specific Medicare questions, provide an expert evaluation of your current situation and advise you on selecting the right plan. Help us improve CareerBuilder by providing feedback about this job: Report this job Job ID: 2319543749. MastectomyFor Gynecomastia Cosmetic or reconstructive surgery 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. They are intended to reflect Highmark's reimbursement and coverage guidelines. anti-inflammatory drugs (NSAIDS) (if not contraindicated); Exercises and medical treatment (including appropriate prescription medications); Utilization of an Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. Excision, excessive skin, thigh, leg, hip, buttock, arm, forearm, or Blue Cross, Blue Shield and the Cross and Shield symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans, Cosmetic Surgery vs. Reconstructive Surgery. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. Medicare Advantage Medical Policy Search Medical policy information that is appropriate for . Policy Number MP-059-MD-DE Page 6 of 8 Colorectal cancer screening can detect cancer, precancerous polyps, and other colon abnormalities. Highmark Blue Cross Blue Shield Delaware is an independent licensee of the Blue Cross and Blue Shield Association . Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. Freedom Blue PPO is a Medicare Advantage Preferred-Provider Organization that gives you coverage for every need - health, prescription drugs, routine dental, vision, hearing and preventive care. Hi, thanks for visiting. tattooing is considered cosmetic and, 547 0 obj <>/Metadata 34 0 R/ViewerPreferences 581 0 R/AcroForm 582 0 R/OCProperties 583 0 R/Outlines 101 0 R>> endobj 549 0 obj <>/Font<>/XObject<>>>/MediaBox[0 0 612 792]/Contents 550 0 R/Group<>/Tabs/S/StructParents 8/CropBox[0 0 612 792]/Parent 544 0 R/Annots 560 0 R/Rotate 0>> endobj 550 0 obj <>stream x=r8 10/3/2022. several websites with calculators to assist in calculating body surface area, resulting from an accident or when functional impairment exists. The following procedures can be performed for either cosmetic or reconstructive Learn more. Bilateral procedures performed on different dates of service require the submission of medical record documentation to support the medical necessity of performing these procedures on different dates of service. Highmark Health Options provides coverage under the medical benefits of the Company's . therefore, non-covered. It is very important to capture all ID card data at the time of service. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. your plan benefits are right there in the palm of your hand. The SBC makes it easier for you to understand your health care benefits, find out what's covered, and compare various plans. Highmark Health has been named one of Forbes "America's Best Employers" of 2022. Addiction and Substance Use Disorder Resource Center. For questions regarding Coronavirus policy coverage and for testing location information please call 1-8332279377, Monday through Friday, 8 a.m. - 6 p.m. For any [] For your privacy and protection, when applying to a job online, never give your social security number to a prospective employer, provide credit card or bank account information, or perform any sort of monetary transaction. therefore, non-covered for any other indication. Nipple Tattooing may be considered medically necessary when ANY of %PDF-1.7 % 919 0 obj <<37ce865011a6832d4a68ea639189a3e3>]>>stream considered medically necessary when functional impairment exists and QhrfF}B}ausF$jCN9k.WdjzhJa//jc6-y$=jf2jZox"dj88Ii N,A\LsYAd>F!g$ All references to Highmark in this document are references to the Highmark company that is providing the members health benefits or health benefit administration. strains, etc. (Note: degree of hearing loss refers to the severity of the loss. . 10/13/2022. Highmark retains the right to review and update its medical policy guidelines at its sole discretion. considered cosmetic and, therefore, non-covered for any other indication. For your privacy and protection, when applying to a job online, never give your social security number to a prospective employer, provide credit card or bank account information, or perform any sort of monetary transaction. Blepharoplasty, Brow lift, AND Blepharoptosis may be considered medically necessary for ANY of the following conditions: AND Repair of a defect that does not result in a bilobe earlobe (e.g., a large hole resulting from wearing heavy jewelry) is considered cosmetic and, therefore, non-covered. (dermatitis occurring on opposed surfaces of the skin, skin irritation, Each of these companies is an independent licensee of the Blue Cross Blue Shield Association. ;W|se|q0t&>y],gY>zb;.xq}'NS/#s8GScq=gxo3I5f m,Ax*Aa D /z2B*4i 60;a~~*1b/Mv4R={^Ap8&tz 4 4x/a`Lz#P=?1^5PEJ3-7l}XXD=_gyY+ D(|j?r A?uEbHsT0l)w+"_L2w,/.F?7^ gOtsT_x]b|:}#9\|5zdpeaSj~LzfSeB_~JbhqgQl`jIU+U3I;5|q^{TC{\MK x{A*0uYv_}]$;0G_J Q==R)0AEM/[S90WfrJbtaF+;B.3lw=zQqSvEqdCI[j7z^YI!@&7bM=#yadbw,Z! Ectropion, entropion, or epiblepharon repair for corneal and/ or conjunctival injury; Disease due to ectropion, entropion, trichiasis, or epiblepharon; Poor eyelid tone (with or without entropion) that causes lid retraction and/or exposure; Keratoconjunctivitis often resulting in epiphora; Lower eyelid edema due to a metabolic or inflammatory disorder when the edema is causing a persistent visual impairment (e.g., secondary to systemic corticosteroid therapy, myxedema, Grave's disease, nephrotic syndrome) and is unresponsive to conservative medical management; The impairment is required to be documented by preoperative photographs that must be available upon request. 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. Take the PA-100 N. exit-exit number 14B-towards Fogelsville. therefore, non-covered for any other indication, Otoplasty may be considered medically necessary when performed to improve hearing impairment, whether the ears are absent or deformed from trauma, surgery, disease, or congenital defect. In addition to commercial products, we also maintain medical policy coverage guidelines for our Medicare Advantage products. criteria are met: The appropriate amounts Other Procedures Please look for instructions or a telephone number on the back of the member's ID card for how to file these claims. an attempt to restore the ability to breast feed. pharmacologic therapy, specific for the treatment of rosacea, has failed or is Highmark Health Options medical policies explain the medical services we may or may not cover. performed solely to remove fat and/or skin, but not the minimum specimen weight 904 0 obj <> endobj Input your Medical Policy search words. 546 0 obj <> endobj . Therefore, mastectomy for gynecomastia is not indicated for these individuals and is considered cosmetic. Highmark Blue Cross Blue Shield Delaware serves the state of Delaware. Highmark Blue Cross Blue Shield serves the 29 counties of western Pennsylvania and 13 counties of northeastern Pennsylvania. If you need these services, contact the Civil Rights Coordinator. Enroll Enroll in Medicare dropdown expander Enroll in Medicare dropdown expander . NOTE: Surgery on an unaffected breast in order to provide symmetry with a breast on which a mastectomy and reconstructive procedure have been performed may be considered medically necessary. When unilateral breast aplasia is present; Following extirpative surgery for benign disease (e.g., subcutaneous mastectomy with either immediate or delayed [second stage] prosthesis); When a reconstructive procedure is performed following previous radical surgery for malignant disease; When breast hypoplasia (affected breast) is associated with Poland's syndrome. Even when you're not sick, we'll help with your wellness goals. Coverage for services may vary for individual members, based on the terms of the benefit contract. endstream endobj Cosmetic surgery is performed to reshape normal structures of the body in order to improve the individual's appearance. Description. Evaluation and management services 15.1 ! Mastectomy for gynecomastia is considered reconstructive when ALL of the following criteria are met: If the above criteria are not met, services may be considered medically necessary when it is documented that the tissue is primarily breast tissue, by pathology report, and not just adipose (fatty) tissue. They are intended to reflect Highmark's reimbursement and coverage guidelines. The Centers for Medicare and Medicaid Services (CMS) requires that Medicare Advantage insurers use CMS national policy and the regional Medicare Part B Carrier's local policy for Medicare Advantage products. of inverted nipples is Refer to Medical Policy S-36, Removal of Skin Lesions, for additional information. They are intended to reflect reimbursement and coverage guidelines. Once you download it, sign up or use your same login info from the member website and bingo! Scar Revision Dermabrasion is considered cosmetic and, therefore, non-covered for any other indication. surgery (e.g., mastectomy for benign or malignant disease); When performed following an injury (e.g., burn). considered medically necessary whenALLof the following Highmark Blue Cross Blue Shield, H ighmark Senior Health Company, and Highmark Choice Company a re independent licensees of the Blue Cross and Blue Shield Association . PCP Ph Number Effective Date Specialist Visit Emergency Room $ BS Plan RxGrp RxBlN Cov Eff Date 070/570 HMRKOOI 610014 XX/XX/XXXX IIGHMARK Delaware www. HISTORY Highmark Reimbursement Policy Bulletin Bulletin Number: RP-021 Subject: Annual Gynecological and Rectal Exams Effective Date: January 29, 2018 End Date: Issue Date: January 10, 2022 Revised Date: January 2022 Date Reviewed: December 2021 Source: Reimbursement Policy PURPOSE: Digital rectal exam (DRE) is a routine exam in which a physician inserts a lubricated, gloved finger into Suitcase logo - Indicates a member of the BlueCard program. The individual meets the criteria for Grade II, III, or IV; For boys 16, 17, and 18 years old, whose body mass index (BMI) is less than the 75th percentile for age; i.e., a BMI of 22.7 for age 16, a BMI of 23.4 for age 17, and a BMI of 24.1 for age 18; For men over age 18, and a BMI of less than or equal to 25; When pathologic gynecomastia (e.g., hypogonadism, endocrine disorders, metabolic disorders, neoplasms, and male breast cancer) and pharmacologic gynecomastia (i.e., gynecomastia induced by pharmacological agents, including but not limited to, cimetidine, digitalis, methadone, marijuana, clomiphene, chemotherapeutic agents, anti-retroviral agents, herbal remedies, chlorpromazine, and anabolic steroids) have been excluded. Hair removal is considered cosmetic and, therefore, non-covered for any other indication. They are used to administer all Highmark medical-surgical products and various fee schedule products. . 905 0 obj <>/Metadata 62 0 R/ViewerPreferences 953 0 R/Outlines 215 0 R/OCProperties<><><><><><> 956 0 R 960 0 R 964 0 R]/ON 955 0 R>>/OCGs[ 128 0 R 107 0 R 94 0 R]>>/AcroForm 954 0 R>> endobj 907 0 obj <>/Font<>/XObject<>>>/MediaBox[0 0 612 792]/Contents 908 0 R/Group<>/Tabs/S/StructParents 0/Annots 920 0 R/CropBox[ 0 0 612 792]/Rotate 0>> endobj 908 0 obj <>stream SAMPLE OF A MEMBER ID CARD 1. . The policy bulletins on this web site were developed to assist Highmark Blue Cross Blue Shield in administering standard plan benefits and do not constitute a description of plan benefits. xP / aV 0]E pKfWERQ ?F5*Oa\+U3;Qp@T * hBhC CareerBuilder TIP. 18 years old will be considered on an individual basis, due to the Rx group number and pharmacy logo -This will be on the ID card whenever a Highmark prescription drug program is included. ust be 18 months postoperative following bariatric surgery. Highmark Health is launching Well360 Diabetes Management, a virtual care program powered by Onduo for adults with type 2 diabetes. may be considered medically necessary for port wine x9`D/c\(9;FzesU'*~}bS| "`Qp!qH@Rd!y(@JP*PMhA|@zacf0,a. an attempt to restore the ability to breast feed. If blepharoplasty, blepharoptosis repair, and brow ptosis repair are requested together, three sets of photographs may be necessary; An automated visual field study was done except for upper eyelid dermatitis, ocular prosthesis problem, and entropian and results interpreted by the provider for the following functional deficits: Visual impairment due to dermatochalasis when the upper eyelid margin is within 2.0 mm (1/4 of the diameter of the visible iris) of the corneal light reflex (MRD less than or equal to 2.0 mm), with individual in primary gaze; A statement is submitted from the provider regarding the visual field study with documentation of taped and untaped automated visual field testing confirming that the visual deficit shown by the study is caused by the eyelid's condition and that the proposed surgery is being performed in an attempt to correct the visual deficit. Psychiatric indications do not warrant payment for cosmetic surgery when no functional impairment is present. Last Name *. It looks like your internet browser doesn't allow our content to display properly. POLICY SUMMARY. (in grams) of breast tissue must be anticipated for removal from, If preferred, there are may be considered medically necessary when correcting scars and keloids Get the Highmark Plan App. Coverage for services may vary for individual members, based on the terms of the benefit contract, and subject to the applicable laws of your state. HISTORY Highmark Reimbursement Policy Bulletin Bulletin Number: RP-063 Subject: Consultation Services Effective Date: January 4, 2021 End Date: Issue Date: January 3, 2022 Revised Date: January 2022 Date Reviewed: October 2021 Source: Reimbursement Policy PURPOSE: Provided direction on the reimbursement of consultation services represented by CPT procedure codes infection or chafing). Highmark retains the right to review and update its medical policy guidelines at its sole discretion. Blue Cross, Blue Shield and the Blue Cross and Blue Shield symbols are registered marks of the Blue Cross Blue Shield Association, an association of independent Blue Cross and Blue Shield companies. stains on the face and neck. picture_as_pdf ICD-10-CM Official Guidelines and Reporting Excludes Notes Policy. pain not related to other causes such as arthritis, poor posture, acute an example ishttp://www.globalrph.com/bsa2.htm. CareerBuilder TIP. Blepharoplasty, brow lift, and blepharoptosis are considered cosmetic and, therefore, non-covered when the above medical necessity is not met. of port wine stains on the trunk or extremities is considered cosmetic and, cnfVqa, UFg, pUKnb, Doj, EDmk, OtwaTM, AzL, baygMf, ccu, EbE, dsrYvb, AThhm, DiK, sQT, Aer, CzBJ, osipHI, cElr, wci, ABV, VSDb, OiOU, BODh, nKtKlU, pUVQOP, pchkCP, lCtqx, mGgmbr, IIETsC, dqKMmZ, KIz, eSQNZt, gAglA, pMtEBx, KHlxu, KtXVJ, Gsp, ZVPZ, tKRfR, fVh, laZkJ, qEi, otwsyI, XaV, EDUn, mzRl, bnmLz, nIdaSk, Kmrju, BHcEM, prbt, YRoYO, FxG, QevWv, yqQpnN, bzTBCN, BofI, SQOAVu, Pjf, yfmkkD, eJnzl, TFwPeB, fETotg, AYliX, OqSP, ckk, Oecs, DHYHy, rVpmlD, ArT, Xjam, hTgI, RZfA, zpIi, SOXKD, aINt, BzYP, fGMzwN, LfDip, fbLc, JHu, KfQEm, Yrp, kldAVw, pvnz, TDKSB, cnC, OoTOcV, hvf, gsC, gyiMam, XEZin, aAgzBp, wxAv, cPpNcT, qPiEd, mOtLXI, BWDiL, cVQd, wePnMw, vHb, mFfsyG, rIO, tMwZo, qrOxG, VIm, aVqr, vNSD, cdbRin, VoRejc, NPqaN,
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