Medicare Advantage Medical Policy Bulletin

Section: Miscellaneous
Number: Z-24
Topic: Miscellaneous Services
Effective Date: January 1, 2009
Issued Date: March 9, 2009

General Policy

This policy contains a list of miscellaneous services that are classified as noncovered for the Medicare Advantage Program.

Indications and Limitations of Coverage

Charges submitted for the items listed below should be denied as indicated.

Item

Not Covered Reason

♦ Adoptive immunotherapy (S2107) Experimental/Investigational ♦
Allergen specific IgE; qualitative, multi-allergen screen (dipstick, paddle, or disk) (86005)

Program Exclusion

♦ Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; single interspace (0195T) Experimental/Investigational ♦
♦ Arthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; each additional interspace (List separately in addition to code for primary procedure)(0196T) Experimental/Investigational ♦
♦ Bilitec 2000

Experimental/Investigational ♦

♦ Body Composition Analyzers/Analysis
 (e.g., Bioelectrical Impedance Analysis)

Not Medically Necessary ♦

♦ Broken appointments (A9270)

Not Covered ♦

♦ Carbon monoxide, expired gas analysis (e.g., ETCO/hemolysis breath test)(84999) Experimental/Investigational ♦

Casted impressions for special shoes (A9270)

Not Covered

♦ Defecography

Not Medically Necessary ♦ 

Hamster egg and human sperm penetration assay (89329, 89330)

Not Medically Necessary

♦ Holotranscobalamin, quantitative (0103T) Experimental/Investigational ♦
Hormonal vaginal ring (e.g., NuvaRing) (J7303) Program Exclusion

Implantable contraceptive capsules (11975, J7306, J7307) (e.g., Implanon)

Program Exclusion

♦ Intraepidermal nerve fiber density testing (e.g., Therapath's ENFE)(89240) Experimental/Investigational ♦

IUD Contraceptives
  (S4989, J7300) Insertion (58300)
  J7302 (Mirena)  Insertion (S4981)

Program Exclusion

♦ Long-chain (C20-22) omega-3 fatty acids in red blood cell membranes (0111T)

Experimental/Investigational ♦

♦ Measurement of ocular blood flow by repetitive intraocular pressure sampling, with interpretation and report (0198T)

Experimental/Investigational ♦

Mileage for medical visit (A9270)

Not Covered

Missed Appointments Program Exclusion

♦Multivariate analysis of patient specific findings with quantifiable computer probability assessment, including report (0185T)

Experimental/Investigational ♦
♦ Nasal/sinus endoscopy (i.e., balloon sinuplasty) (S2344) Experimental/Investigational ♦

Nicotine Cessation Program (S9075)

Program Exclusion
♦Ocular Photoscreening (99174) Experimental/Investigational ♦

Removal of IUD, not under regional or general anesthesia (58301)

Program Exclusion

Removal; implantable contraceptive capsules (11976)

Program Exclusion

Removal with reinsertion, implantable contraceptive capsules (11977)

Program Exclusion

♦ Saliva test, hormone level; during menopause (S3650)

Experimental/Investigational ♦

♦ Saliva test, hormone level; to assess preterm labor (S3652)

Experimental/Investigational ♦

♦ Sperm evaluation, DNA integrity (e.g., sperm chromatin assays and sperm DNA fragmentation assays) Experimental/Investigational ♦
♦ Sperm evaluation, Hyaluronan sperm binding test (0087T)

Experimental/Investigational ♦

Therapeutic wigs (A9282)

Program Exclusion

♦Transurethral, radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence (0193T)

Experimental/Investigational ♦

♦ Whole body integumentary photography (96904) Not Covered ♦

Work related injuries

Program Exclusion

+ New Item

The reasons for denial are as follows:

Not Covered

Action Taken by the Board of Directors or Management

Non-billable
Program Exclusion

Specifically excluded in the Member's Contract

Billable

Not Medically Necessary

Excluded on the basis that the procedure is not clinically recognized/widely accepted.

Effective January 26, 2009, a provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost.  The member must agree in writing to assume financial responsibility, in advance of receiving the service.  The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Experimental/Investigational  

Excluded on the basis that the procedure is in the research/investigational stage.

Billable

Where appropriate, documentation to support medical necessity should be indicated.

NOTE:
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.

Procedure Codes

119751197611977583005830184999
860058691589240893298933096904
99174A9270A9282J7300J7302J7303
J7306J7307S2107S2344S3650S3652
S4981S4989S90750087T0103T0111T
0185T0193T0195T0196T0198T 

Coding Guidelines

References

CMS On-Line Publication 100.04, Chapter 20, Section 10.1.2

CMS On-Line Publication 100.02, Chapter 16, Sections 40.3, and 150

Medicare Advantage Evidence of Coverage

Medicare Fee Schedule Data Base Status Indicator


www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary





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.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.