Notification



Notification Issue Date:



Medical Policy Bulletin


Title:Treatment of Medical and Surgical Complications

Policy #:11.00.02f

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.

The treatment of medical and surgical complications is considered medically necessary and, therefore, covered when, if left untreated, the complications would endanger the health of the individual. Medical and surgical complications include, but are not limited to, complications resulting from cosmetic or other noncovered procedures. Treatment is covered and eligible for reimbursement consideration by the Company based on the medical necessity for acute conditions such as, but not limited to:
  • Deep vein thrombosis (DVT)
  • Hemorrhage
  • Incisional Hernia
  • Infection
  • Myocardial infarction (MI)
  • Wound dehiscence

Outcomes following cosmetic procedures that have unsatisfactory cosmetic results are not considered medical or surgical complications and are, therefore, not covered by the Company.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the treatment of medical and surgical complications is covered under the medical benefits of the Company’s products when the medical necessity criteria listed in this medical policy are met.

Description

A complication is an untoward event that occurs in the course of another condition or during its treatment. Complications may be of either medical or surgical origin, may modify the course of the original condition, and may require revisions to the treatment plan.

Medical and/or surgical therapy for untoward events may be necessary to correct functional impairment of a body part or system. Additionally, medical and/or surgical therapy for untoward events may be therapeutic for purposes which coincidentally also serve a cosmetic purpose (e.g., treatment of severe burns following accidental trauma). Typically, cosmetic services are those provided to improve an individual’s physical appearance, from which no significant improvement in physiologic function can be expected. Emotional and/or psychological improvement does not constitute improvement in physiologic function.
References


Andersen LP, Klein M, Rosenberg J. Long-term recurrence and complication rates after incisional hernia repair with open onlay technique. BioMed Central. April 28, 2009. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684736/
Accessed October 26, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare Home Health Agency Manual. Transmittal 301. 232.11: Cosmetic surgery. [CMS Web site]. 06/06/02. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R301HHA.pdf Accessed October 26, 2018.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination. Routine Costs in Clinical Trials (310.1). [CMS Web site]. 10/09/07. http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=1&ncdver=2&fromdb=true. October 26, 2018.

Company Benefit Contracts.

Novitas Solutions, Inc. Medicare Part B Reference Manual. Chapter 22 - Global Surgery & Related Services. [Novitas Solutions Web site].






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)

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 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)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References


Policy History

Revisions from 11.00.02f
12/05/2018This policy has been reviewed and reissued to communicate the Company's continuing position on Treatment of Medical and Surgical Complications.


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


Version Effective Date: 08/26/2015
Version Issued Date: 08/26/2015
Version Reissued Date: 12/05/2018

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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.