Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Obsolete or Unreliable Diagnostic Tests and Medical Services

Policy #:00.01.24g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.


The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

Obsolete or unreliable diagnostic tests and medical services are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

LAB TESTS

The following diagnostic tests are considered obsolete or unreliable and have been replaced by more advanced testing procedures:
  • Amylase, blood isoenzymes, electrophoretic
  • Animal inoculation, small animal; with observation
  • Animal inoculation, small animal; with observation and dissection
  • Bendien's test for cancer and tuberculosis
  • Bolen's test for cancer (Bolen's clot retraction test)
  • Calcium, feces, 24-hour quantitative
  • Calcium saturation clotting time
  • Capillary fragility test (Rumpel-Leede)
  • Cephalin flocculation
  • Chromium, blood
  • Chymotrypsin, duodenal contents
  • Circulation time, one test
  • Colloidal gold
  • Congo red, blood
  • Gastric analysis, pepsin
  • Gastric analysis, tubeless
  • Guanase, blood
  • Hair analysis
  • Hormones, adrenocorticotropin quantitative animal tests
  • Hormones, adrenocorticotropin quantitative bioassay
  • Rehfuss test for gastric acidity
  • Serum seromucoid assay for cancer and other diseases
  • Skin test, actinomycosis
  • Skin test, brucellosis
  • Skin test, cat scratch fever (cat scratch disease; Bartonella infection)
  • Skin test, lymphopathia venereum
  • Skin test, psittacosis
  • Skin test, trichinosis
  • Starch, feces, screening
  • Thymol turbidity, blood
  • Zinc sulphate turbidity, blood

MEDICAL SERVICES

The following medical services are considered obsolete or unreliable, and as such are not appropriate with regard to generally accepted standards of medical practice within the medical community:
  • Adrenal tissue transplant to the brain
  • Arthroscopic electrothermal joint repair
  • Cardiointegram (CIG)
  • Continuous noninvasive glucose monitoring using the Glucowatch
  • Fabric wrapping of abdominal aortic aneurysms
  • Intracardiac phonocardiogram
  • Intragastric hypothermia (Gastric freezing)
  • Phonocardiogram with electrocardiogram (ECG) lead, with indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram; with interpretation and report
  • Phonocardiogram with or without electrocardiogram (ECG) lead; with supervision during recording with interpretation and report (when equipment is supplied by the physician)
  • Phonocardiogram; tracing only, without interpretation and report (eg, when equipment is supplied by the hospital, clinic)
  • Phonocardiogram; without interpretation and report
  • Phonocardiogram; interpretation and report only
  • Vectorcardiogram (VCG), with or without electrocardiogram (ECG); with interpretation and report
  • Vectorcardiogram (VCG); tracing only, without interpretation and report
  • Vectorcardiogram (VCG); interpretation and report only

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, obsolete or unreliable diagnostic tests and medical services are not eligible for payment under the medical benefits of the Company's products because these tests and services are considered not medically necessary and, therefore, not covered.

Description

Obsolete or unreliable diagnostic tests are tests that are no longer routinely used and, in some instances, are outdated and found to be of little clinical value. Some of these tests have been replaced with improved technology. The obsolete or unreliable medical services included in this policy are services or treatments that are rarely performed and lack scientific or statistical evidence in peer-reviewed literature to document their effectiveness. Service are not appropriate with regard to generally accepted standards of medical practice within the medical community.

In 2006, the Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) identifying obsolete or unreliable diagnostic and cardiovascular tests.
References


American Academy of Orthopaedic Surgeons (AAOS). Thermal capsulorrhaphy. [AAOS Web site]. October 2007 (last reviewed September 2010). Available at:http://orthoinfo.aaos.org/topic.cfm?topic=a00034. Accessed November 6, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). Fabric Wrapping of Abdominal Aneurysms (20.23). [CMS web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=51&ncdver=1&DocID=20.23&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD).20.27 Cardiointegram (CIG) as an Alternative to Stress Test or Thallium Stress Test [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=259&ncdver=1&DocID=20.27&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 100.6: Gastric freezing [CMS Web site]. Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=87&ncdver=1&DocID=100.6&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 190.6 Hair Analysis [CMS Web site]. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=189&ncdver=1&DocID=190.6&bc=gAAAABAAAAAA&. Accessed November 20, 2018.

Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD). 300.1: Obsolete or unreliable diagnostic tests. [CMS Web site]. 06/19/06. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=204&ncdver=2&DocID=300.1&bc=gAAAABAAAAAA&. Accessed Accessed November 20, 2018.

Chen S, Haen PS, Walton J, et al. The effects of thermal capsular shrinkage on the outcomes of arthroscopic stabilization for primary anterior shoulder instability. Am J Sports Med. 2005; 33(5):705-11.

D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am J Sports Med. 2004;32(1):21-33.

Jansen N, Van Riet RP, Meermans G, et al. Thermal capsulorrhaphy in internal shoulder impingement: a 7-year follow-up study. Acta Orthop Belg. 2012;78(3):304-8.

Mohtadi NG, Hollinshead RM, Ceponis PJ, et al. A multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT [ISRCTN68224911; NCT00251160]. Trials. 2006;7:4.

Oakes DA, McAllister DR. Failure of heat shrinkage for treatment of a posterior cruciate ligament tear. Arthroscopy. 2003;19(6):E1-E4.





Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

87003



TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 29999:

Arthroscopic electrothermal joint repair


TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 84999:

Amylase, blood isoenzymes, electrophoretic

Bolen's test for cancer (Bolen's clot retraction test [CRT])

Colloidal gold, spinal

Chromium, blood

Chymotrypsin; duodenal contents

Gastric analysis, pepsin

Gastric analysis, tubeless

Guanase, blood

Hormones, adrenocorticotropin quantitative animal tests

Hormones, adrenocorticotropin quantitative bioassay

Starch, Feces, Screening


TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 85999:

Calcium saturation clotting time

Capillary fragility test (Rumpel-Leede)

Circulation time, one test


TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 86486:

Skin test, Actinomycosis

Skin test, Brucellosis

Skin test, Cat scratch fever (cat scratch disease; Bartonella Infection)

Skin test, Lymphopathia venereum

Skin test, Psittacosis

Skin test, Trichinosis


TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 89240:

Bendien's test for cancer and tuberculosis

Calcium, feces, 24-hour quantitative

Zinc sulphate turbidity, blood


TO REPORT THE FOLLOWING SERVICE, USE THE UNLISTED CODE, 91299:

Rehfuss test for gastric acidity


TO REPORT THE FOLLOWING SERVICES, USE THE UNLISTED CODE, 93799:

Intracardiac phonocardiogram

Phonocardiogram with ECG lead, with indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram; with interpretation and report

Phonocardiogram with or without ECG lead; with supervision during recording with interpretation and report (when equipment is supplied by the physician)

Phonocardiogram; tracing only, without interpretation and report (eg, when equipment is supplied by the hospital, clinic)

Phonocardiogram; without interpretation and report

Phonocardiogram; interpretation and report only

Vectorcardiogram (VCG), with or without ECG; with interpretation and report

Vectorcardiogram; tracing only, without interpretation and report

Vectorcardiogram; interpretation and report only



Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)


M0100 Intragastric hypothermia using gastric freezing

M0301 Fabric wrapping of abdominal aneurysm

P2028 Cephalin flocculation, blood

P2029 Congo red, blood

P2031 Hair analysis (excluding arsenic)

P2033 Thymol turbidity, blood

P2038 Mucoprotein, blood (seromucoid)

S1030 Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use CPT code)

S1031 Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use CPT code)

S2103 Adrenal tissue transplant to brain

S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy

S9025 Omnicardiogram/cardiointegram



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

00.01.24g
01/14/2019This version of the policy will become effective 01/14/2019. The following medical service was added to the policy: arthroscopic electrothermal joint repair. The following codes have been added to the policy: 29999, S2300.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/14/2019
Version Issued Date: 01/14/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.