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.
27096, 62320, 62321, 62322, 62323, 64451, 64461, 64462, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 77003, 77012
NOT MEDICALLY NECESSARY
0213T, 0214T, 0215T, 0216T, 0217T, 0218T, 0228T, 0229T, 0230T, 0231T
Policy: 00.01.25av:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Policy: 00.03.02y:Diagnostic Radiology Services Included in Capitation
Policy: 08.00.57n:Treatments for Complex Regional Pain Syndrome (CRPS)
Policy: 11.15.09m:Denervation of the Spinal Nerves for Chronic Pain
Policy: 11.15.15g:Percutaneous Discectomy