This version of the policy will become effective 04/12/2021. This has been updated to communicate the reimbursement position of all services not eligible for reimbursement or not eligible for separate reimbursement by the Company. Attachments B and C have been introduced to this policy to represent services that are not eligible for separate reimbursement or not eligible for reimbursement and were previously communicated in other policies.
The following criteria have been added to the policy:- The procedure codes listed in Attachment B may be covered by the Company; however, are not eligible for separate reimbursement consideration whether billed alone or in conjunction with other services. Participating providers may not bill members for these services.
- The procedure codes listed in Attachment C may be covered by the Company; however, they are not eligible for reimbursement consideration. Participating providers may not bill members for these services.
The following CPT code has been added to this policy in attachment B and is not eligible for separate reimbursement. This position was previously communicated in other policies:
92285 
