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Not Medically Necessary Services and Obsolete or Unreliable Diagnostic Tests
00.01.24n

Policy

Obsolete or unreliable diagnostic tests, medical services, and pharmaceutical products and​ 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.

DIAGNOSTIC 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The following diagnostic tests are considered obsolete or unreliable and have been replaced by more advanced testing procedures: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 test for cancer (Bolen 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 due to having limited clinical usefulness​, 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 or thermal capsulorrhaphy or electrothermal capsulorrhaphy or thermal or electrothermal shrinkage
  • ​Cardiointegram (CIG)
  • Continuous noninvasive glucose monitoring using the Glucowatch
  • Electron beam computed tomography (EBCT)
  • Fabric wrapping of abdominal aortic aneurysms
  • Home uterine activity monitoring (HUAM) devices
  • Intracardiac phonocardiogram
  • Intragastric hypothermia (gastric freezing)
  • Phonocardiogram with or without electrocardiogram (ECG) lead, with or without indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram
  • Photocoagulation of macular drusen
  • Transtympanic micropressure device
  • Vectorcardiogram (VCG), with or without electrocardiogram (ECG); with or without tracing​
PHARMACEUTICAL PRODUCTS 

Pharmaceutical products are considered not medically necessary when the approved authorization has been rescinded​ by the US Food and Drug Administration (FDA) for a specific approved condition or diagnosis​ or the product has been withdrawn from the market based on having limited clinical usefulness or in situations​ in which the available published peer-reviewed literature does not support its use, and as such are not appropriate with regard to generally accepted standards of medical practice within the medical community:​​​

  • Hydroxyprogesterone caproate (Makena and compounded or generic products) to reduce the risk of preterm birth 

  • Olaratumab (Lartruvo)​

  • Copanlisib (Aliqopa) 
  • Tocolytic infusion therapy (i.e., Terbutaline sulfate) for prevention or treatment of preterm labor (<37 weeks) exceeding 72 hours or administered in the home setting.​​

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, not medically necessary services and obsolete or unreliable diagnostic tests 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 not medically necessary 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. These services are not appropriate with regard to generally accepted standards of medical practice within the medical community due to having limited clinical usefulness. ​

References

American Academy of Ophthalmology. Retina/Vitreous Committee. Preferred Practice Pattern Guidelines. Age-Related Macular Degeneration. San Francisco, CA: American Academy of Ophthalmology; 2019. Available at: https://www.aao.org/education/preferred-practice-pattern/age-related-macular-degeneration-ppp.


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 June 28, 2025.


American Academy of Otolaryngology–Head and Neck Surgery. AAO-HNS position on micropressure therapy. 2012. Available at: https://www.entnet.org/resource/position-statement-micropressure-therapy/. Accessed June 28, 2025.


American Academy of Otolaryngology–Head and Neck Surgery. Available at: http://www.enthealth.org/conditions/menieres-disease. Accessed April 18, 2024.


American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin No. 130: Prediction and Prevention of Preterm Birth. Obstet Gynecol. 2012;120:964-973. Reaffirmed 2016.


American College of Obstetricians and Gynecologists; Committee on Practice Bulletins—Obstetrics. ACOG practice bulletin no. 171: Management of preterm labor. Obstet Gynecol. 2016;128:e155-164 (Interim Update).


American Hospital Formulary Service (AHFS). Terbutaline sulfate injection. AHFS Drug Information 2023. [LexiComp Web site]. 12/12/2023. Available at: https://online.lexi.com/lco/action/home [via subscription only]. Accessed June 28, 2025.


Centers for Medicare & 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 June 28, 2025.


Centers for Medicare & 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 June 28, 2025.


Centers for Medicare & 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 June 28, 2025.


Centers for Medicare & 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 June 28, 2025.


Centers for Medicare & 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 June 28, 2025.


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):705-711.


Choroidal Neovascularization Prevention Trial Research Group. Choroid neovascularization in the Choroidal Neovascularization Prevention Trial. Ophthalmology. 1998;105(8):1364-1372.


Choroidal Neovascularization Prevention Trial Research Group. Laser treatment in fellow eyes with large drusen: Updated findings from a pilot randomized clinical trial. Ophthalmology. 2003;110(5):971-978.


Complications of Age-Related Macular Degeneration Prevention Trial Research Group. Laser treatment in patients with bilateral large drusen: The complications of age-related macular degeneration prevention trial. Ophthalmology. 2006;113(11):1974-1986.


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.


Figueroa MS, Regueras A, Bertrand J. Laser photocoagulation to treat macular soft drusen in age-related macular degeneration. Retina. 1994;14(5):391-396.


Figueroa MS, Regueras A, Bertrand J, et al. Laser photocoagulation for macular soft drusen. Updated results. Retina. 1997;17(5):378-384.


Folk JC, Russell SR. Can laser photocoagulation of eyes with high-risk drusen prevent vision loss from age-related macular degeneration? Ophthalmology. 1999;106(7):1241-1242.


Friberg TR, Brennen PM, Freeman WR, et al.; PTAMD Study Group. Prophylactic treatment of age-related macular degeneration report number 2: 810-nanometer laser to eyes with drusen: bilaterally eligible patients. Ophthalmic Surg Lasers Imaging. 2009;40(6):530-538.


Friberg TR, Musch DC, Lim JI, et al. Prophylactic treatment of age-related macular degeneration report number 1: 810-nanometer laser to eyes with drusen. Unilaterally eligible patients. Ophthalmology. 2006;113(4):622.e1.


Frennesson IC. Prophylactic laser treatment in early age-related maculopathy: An 8-year follow-up in a randomized pilot study shows a reduced incidence of exudative complications. Acta Ophthalmol Scand. 2003;81(5):449-454.


Frennesson IC, Nilsson SE. Effects of argon (green) laser treatment of soft drusen in early age-related maculopathy: A 6-month prospective study. Br J Ophthalmol. 1995;79(10):905-909.


Frennesson IC, Nilsson SE. Prophylactic laser treatment in early age-related maculopathy reduced the incidence of exudative complications. Br J Ophthalmol. 1998;82(10):1169-1174.


Gates GA, Green JD. Intermittent pressure therapy of intractable Ménière's disease using the Meniett device: a preliminary report. Laryngoscope. 2002;112(8 pt 1):1489-1493.


Gates GA, Green JD, Tucci DL, et al. The effects of transtympanic micropressure treatment in people with unilateral Ménière's disease. Arch Otolaryngol Head Neck Surg. 2004;130(6):718-725.


Gates GA, Verrall A, Green JD, Jr., et al. Meniett clinical trial: long-term follow-up. Arch Otolaryngol Head Neck Surg. 2006;132(12):1311-1316.


Grundy SM, Stone NJ, Bailey AL, et al. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73(24):3168-3209.


Gurkov R, Filipe Mingas LB, Rader T, et al. Effect of transtympanic low-pressure therapy in patients with unilateral Ménière's disease unresponsive to betahistine: a randomised, placebo-controlled, double-blinded, clinical trial. J Laryngol Otol. 2012;126(4):356-362.


Ho AC, Maguire MG, Yoken J, et al. Laser-induced drusen reduction improves visual function at 1 year. Choroidal Neovascularization Prevention Trial Research Group. Ophthalmology. 1999;106(7):1367-1374.


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):304-308.


Kazandjian D. Multiple myeloma epidemiology and survival: A unique malignancy. Semin Oncol. 2016;43(6):676-689.


Kramer CM, Villines TC. Coronary artery calcium scoring (CAC): Overview and clinical utilization. UpToDate. [UpToDate Web site]. 08/23/2022. Available at: http://www.uptodate.com/home/index.html [via subscription only].


Kulkarni S, Rumberger JA, Jha S. Electron Beam CT: A Historical Review. AJR Am J Roentgenol. 2021;216(5):1222-1228.


Lenassi E, Troeger E, Wilke R, et al. Laser clearance of drusen deposit in patients with autosomal dominant drusen (p.Arg345Trp in EFEMP1). Am J Ophthalmol. 2013;155(1):190-198.


Lonial S, Lee HC, Badros A, et al. Belantamab mafodotin for relapsed or refractory multiple myeloma (DREAMM-2): a two-arm, randomised, open-label, phase 2 study. Lancet Oncol. 2020;21(2):207-221.


Maguire M, Complications of Age-Related Macular Degeneration Prevention Trial Research Group (CAPT). Baseline characteristics, the 25-Item National Eye Institute Visual Functioning Questionnaire, and their associations in the Complications of Age-Related Macular Degeneration Prevention Trial (CAPT). Ophthalmology. 2004;111(7):1307-1316.


Matasar MJ, Dreyling M, Leppä S, et al. Feasibility of combining the phosphatidylinositol 3-kinase inhibitor copanlisib With rituximab-based immunochemotherapy in patients with relapsed indolent B-cell Lymphoma. Clin Lymphoma Myeloma Leuk. 2021;21(11):e886-e894.


Mattox DE, Reichert M. Meniett device for Ménière's disease: use and compliance at 3 to 5 years. Otol Neurotol. 2008;29(1):29-32.


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.


National Cancer Institute. The surveillance, epidemiology, and end results (SEER) Cancer Facts & Figures 2019. Available at: https://seer.cancer.gov/statfacts/html/mulmy.html. Accessed June 28, 2025.


National Institute for Clinical Excellence (NICE). Micropressure therapy for refractory Ménière's disease. NICE interventional procedure guidance 426. 2012: Available at: https://www.nice.org.uk/guidance/ipg426/chapter/1-Guidance. Accessed June 28, 2025.


National Institute of Child Health and Human Development. Home uterine monitors not useful for predicting premature birth. January 23, 2002. Available at: https://www.nichd.nih.gov/newsroom/releases/uterine. Accessed June 28, 2025.


Nooka AK, Kastritis E, Dimopoulos MA. Treatment options for relapsed and refractory multiple myeloma. Blood. 2015;125(20):3085-3099.


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


Olk RJ, Friberg TR, Stickney KL, et al. Therapeutic benefits of infrared (810-nm) diode laser macular grid photocoagulation in prophylactic treatment of nonexudative age-related macular degeneration: Two-year results of a randomized pilot study. Ophthalmology. 1999;106(11):2082-2090.


Owens SL, Bunce C, Brannon AJ, et al. Prophylactic laser treatment hastens choroidal neovascularization in unilateral age-related maculopathy: Final results of the drusen laser study. Am J Ophthalmol. 2006;141(2):276-281.


Parodi MB, Virgili G, Evans JR. Laser treatment of drusen to prevent progression to advanced age-related macular degeneration. Cochrane Database Syst Rev. 2009;(3):CD006537.


Reinsch N, Mahabadi AA, Lehmann N, et al. Comparison of dual-source and electron-beam CT for the assessment of coronary artery calcium scoring. Br J Radiol. 2012;85(1015):e300-e306.


Russo FY, Nguyen Y, De Seta D, et al. Meniett device in Ménière disease: randomized, double-blind, placebo-controlled multicenter trial. Laryngoscope. 2017;127(2):470-475.


Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30.


Syed MI, Rutka JA, Hendry J, et al. Positive pressure therapy for Ménière's syndrome/disease with a Meniett device: a systematic review of randomised controlled trials. Clin Otolaryngol. 2015;40(3):197-207.


Thomsen J, Sass K, Odkvist L, et al. Local overpressure treatment reduces vestibular symptoms in patients with Ménière's disease: a clinical, randomized, multicenter, double-blind, placebo-controlled study. Otol Neurotol. 2005;26(1):68-73.


Urquhart C, Currell R, Harlow F, et al. Home uterine monitoring for detecting preterm labour. Cochrane Database Syst Rev. 2017;2:CD006172.


US Food and Drug Administration (FDA). Drug Safety and Availability. [FDA Web Site]. 08/04/2017. Available at: https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-new-warnings-against-use-terbutaline-treat-preterm-labor. Accessed June 28, 2025.


US Food and Drug Administration (FDA). FDA Drug Safety Communication: New warnings against use of terbutaline to treat preterm labor. [FDA Web site]. 02/24/2011. Available at: https://web.archive.org/web/20150918082954/http://www.fda.gov/Drugs/DrugSafety/ucm243539.htm. Accessed June 28, 2025.


US Food and Drug Administration. Federal Register. Bayer HealthCare Pharmaceuticals Inc.; Withdrawal of approval of new drug application for ALIQOPA (Copanlisib). 03/18/2024. Available at: https://www.govinfo.gov/content/pkg/FR-2024-03-18/pdf/2024-05619.pdf. Accessed June 28, 2025.


US Food and Drug Administration. Federal Register. Eli Lilly and Co.; Announcement of the revocation of the biologics license for LARTRUVO. 07/17/2020. Available at: https://www.federalregister.gov/documents/2020/07/17/2020-15516/eli-lilly-and-co-announcement-of-the-revocation-of-the-biologics-license-for-lartruvo. Accessed June 28, 2025.


US Food and Drug Administration. Federal Register. Final decision on withdrawal of MAKENA (hydroxyprogesterone caproate) and eight abbreviated new drug applications following public hearing; availability of final decision. 05/15/2023. Available at: https://www.federalregister.gov/documents/2023/05/15/2023-10264/final-decision-on-withdrawal-of-makena-hydroxyprogesterone-caproate-and-eight-abbreviated-new-drug. Accessed June 28, 2025.


US Food and Drug Administration. Makena (hydroxyprogesterone caproate injection) information. 04/06/2023. Available at: https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/makena-hydroxyprogesterone-caproate-injection-information. Accessed June 28, 2025.


US Preventive Services Task Force. Screening Home Uterine Activity Monitoring. January 1996. Available at: http://www.uspreventiveservicestaskforce.org. Last accessed on September 7, 2017.

​
Virgili G, Michelessi M, Parodi MB, et al. Laser treatment of drusen to prevent progression to advanced age-related macular degeneration. Cochrane Database Syst Rev. 2015;(10):CD006537.

Coding

CPT Procedure Code Number(s)

87003​

The following code is used to represent Arthroscopic electrothermal joint repair, Thermal capsulrorrhaphy, Electrothermal capsulorrhaphy, and Thermal or electrothermal shrinkage procedures:

29999

The following code is used to represent Photocoagulation of Macular Drusen procedure:​ ​​ 

67299​

The following code is used to represent Amylase, blood isoenzymes, electrophoretic, Bolen's test for cancer (Bolen's clot retraction test [CRT]), Colloidal gold, Chromium, blood, Chymotrypsin; duodenal contents, Gastric analysis, pepsin, Gastric analysis, tubeless, Guanase, blood, Hormones, adrenocorticotropin quantitative animal tests, Hormones, adrenocorticotropin quantitative bioassay, and Starch, Feces, Screening procedures:

84999

The following code is used to represent Calcium saturation clotting time, Capillary fragility test (Rumpel-Leede), and Circulation time, one test procedures:

85999 

The following code is used to represent Skin test, Actinomycosis, Skin test, Brucellosis, Skin test, Cat scratch fever (cat scratch disease; Bartonella Infection), Skin test, Lymphopathia venereum, Skin test, Psittacosis, and Skin test, Trichinosis:

86486

The following code is used to represent Bendien's test for cancer and tuberculosis, Calcium, feces, 24-hour quantitative, and Zinc sulphate turbidity, blood tests:

89240

The following code is used to represent Rehfuss test for gastric acidity procedure:

91299

The following code is used to represent​ Intracardiac phonocardiogram, Phonocardiogram with or without electrocardiogram (ECG) lead, with or without indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram, and Vectorcardiogram (VCG), with or without electrocardiogram (ECG); with or without tracing SER services:

93799​
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)

A4638 Replacement battery for patient-owned ear pulse generator, each

 

E2120 Pulse generator system for tympanic treatment of inner ear endolymphatic fluid

 

J1726 Injection, hydroxyprogesterone caproate, (Makena), 10 mg

 

J9057 Injection, copanlisib, 1 mg

 

J9285 Injection, olaratumab, 10 mg

 

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

 

S8092 Electron beam computed tomography (also known as ultrafast CT, cine CT)

 

S9001 Home uterine monitor with or without associated nursing services

 

S9025 Omnicardiogram/cardiointegram

 

THE FOLLOWING CODE IS USED TO REPRESENT hydroxyprogesterone caproate, (Makena) TO REDUCE THE RISK OF PRETERM BIRTH:

 

J1729 Injection, hydroxyprogesterone caproate, not otherwise specified, 10 mg

 

THE FOLLOWING CODE IS USED TO REPRESENT TOCOLYTIC THERAPY FOR THE TREATMENT OF PRETERM LABOR IN THE HOME SETTING:

 

S9349 Home infusion therapy, tocolytic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem​​



Revenue Code Number(s)
N/A


Coding and Billing Requirements

Policy History

Revisions From 00.01.24n:
01/12/2026This version of the policy will become effective 01/12/2026.​

The following medical service was added to the policy as Not Medically Necessary: Photocoagulation of macular drusen.​

The following CPT code has been added to this policy:​ 67299.

Revisions From 00.01.24m:
09/08/2025This policy will become effective on 09/08/2025.​

The following pharmaceutical product was added to the policy: tocolytic infusion therapy (i.e., terbutaline sulfate) in the home setting​.

The following HCPCS code was added to the policy:

​S9349 Home infusion therapy, tocolytic​ infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Revisions From 00.01.24l:
04/01/2025This policy has been identified for HCPCS code update, effective 04/01/2025.

The following codes have been DELETED from the policy:

J9037 Injection, Misspelled Wordbelantamab Misspelled Wordmafodontin-blmf, 0.5 mg
J9247 Injection, Misspelled Wordmelphalan Misspelled Wordflufenamide, 1 mg​

Revisions From 01.01.24k:
06/03/2024
This version of the policy will become effective 06/03/2024. ​​

​The following pharmaceutical products were added to the policy: 
  • ​Misspelled WordCopanlisib (Misspelled WordAliqopa) 
The following HCPCS codes have been added to the policy:

​J9057 Injection, Misspelled Wordcopanlisib, 1 mg​​

Revisions From 01.01.24j:
07/01/2023
This version of the policy will become effective 07/01/2023. The policy title was updated to: Not Medically Necessary Services and Obsolete or Unreliable Diagnostic Tests.

The following medical service was added to the policy: electron beam computed tomography (EBCT).​

Policy coverage statement was added to include pharmaceutical products. The following pharmaceutical products were added to the policy: 
  • Single-agent ​Misspelled Wordbelantamab Misspelled Wordmafodotin-blmf (Misspelled WordBlenrep) ​
  • Misspelled WordHydroxyprogesterone Misspelled Wordcaproate (Makena and generic products) 
  • Misspelled WordMelphalan Misspelled Wordflufenamide (Misspelled WordPepaxto)
  • Misspelled WordOlaratumab (Misspelled WordLartruvo) 
The following codes have been added to the policy: 
J1726 Injection, Misspelled Wordhydroxyprogesterone Misspelled Wordcaproate, (Makena), 10 mg
J1729 Injection, Misspelled Wordhydroxyprogesterone Misspelled Wordcaproate, not otherwise specified, 10 mg
J9037 Injection, Misspelled Wordbelantamab Misspelled Wordmafodontin-blmf, 0.5 mg
J9247 Injection, Misspelled Wordmelphalan Misspelled Wordflufenamide, 1 mg
J9285 Injection, Misspelled Wordolaratumab, 10 mg
S8092 Electron beam computed tomography (also known as ultrafast CT, cine CT)​​

Revisions From 01.01.24i:
11/21/2022
​This version of the policy will become effective 11/21/2022. The following medical service was added to the policy: Misspelled Wordtranstympanic Misspelled Wordmicropressure device. The following codes have been added to the policy:  A4638,E2120.​

Revisions From 00.01.24h:
06/30/2021This policy has been reissued in accordance with the Company's annual review process.​
​10/07/2020

​This policy has been reissued in accordance with the Company's annual review process.​
​05/06/2019
​This version of the policy will become effective 05/06/2019. The following medical device was added to the policy: home uterine activity monitoring devices. The following HCPCS code has been added to the policy:

S9001 Home uterine monitor with or without associated nursing services (Not Medically Necessary)
​
Revisions From 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 Misspelled Wordelectrothermal 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.
1/12/2026
1/12/2026
00.01.24
Medical Policy Bulletin
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.