Miscellaneous Services

Policy ID: Z-24-113

Section: Miscellaneous

Effective Date: January 01, 2020

Revised Date: January 07, 2025

Revision Effective Date: March 03, 2025

Last Reviewed: January 14, 2025

Applies To: Commercial and Medicaid Expansion

Description

This policy addresses those services considered to be miscellaneous and are typically not covered services.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

ALL services on this policy are non-covered for ONE of the following reasons:

The service is considered not medically necessary because it does not meet the definition of medical necessity; or
The service is a program exclusion/not a benefit; or

Not Medically Necessary

The following services are considered not medically necessary:

Anal fistula plug
Carbon monoxide, expired gas analysis (e.g., ETCO/hemolysis breath test)
Continuous Passive Motion (CPM) remote stationary cycling device (i.e., ROM3 ^® Rehab, ROMTech AccuAngle ^® , ROMTech PortableConnect ^® )
Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) (ImmuKnow®)
Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
Ferriscan
Idiopathic Environmental Intolerance - treatment and testing (e.g., intracellular analysis of micronutrients, ALCAT, IVIg)
Multivariate analysis of individual-specific findings with quantifiable computer probability assessment, including report
Neuro-selective current perception threshold (CPT/SNCT)Sensory Nerve Conduction Test
Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or arterial, venous, or capillary glucose; and/or potassium concentration
pH; exhaled breath condensate
Posturography (dynamic or static)
PreDx (Diabetes Risk Score)
Saliva test, hormone level; to assess preterm labor
Saliva test, hormone level; during menopause
Tenotomy of elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow; percutaneous)
Thromboxane metabolite(s), including thromboxane if performed, urine
Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
InfraScanner Handheld Brain Hematoma Screening System For Early Detection of Intracranial Hemorrhage (ICH)
Defecography
Grenz Ray Therapy
Hair analysis
Lixiscope Service

Procedure Codes

24357

29999

46707

53860

74270

76498

77499

83987

84431

84999

86352

92548

92549

93998

99199

E1399

G0255

G9147

P2031

S2107

S2300

S3650

S3652

Program Exclusion/Not a Benefit

A program exclusion/not a benefit is defined as EITHER ONE of the following:

Services generally not covered under the specified program(s); or
Groups define benefits, and determine coverage

The following services are considered a program exclusion/not a benefit, and therefore non-covered:

Casted impressions for special shoes
EROS-Clitoral Therapy Device as a treatment of female sexual dysfunction
Hearing aid evaluation
Recreational or educational therapy (inpatient)

Procedure Codes

92590

92591

92592

92593

92594

92595

A9270

S0395

Medically Necessary

Policy Application

Bioimpedance spectroscopy for lymphedema is considered medically necessary for cancer survivors at risk for lymphedema as per the NCCN Guidelines. All other indications are considered experimental/investigational.

Procedure Code

93702

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 All four (4) of these policies :

Thermal Capsulorrhaphy for Joint Instability (BCBSA archived March 2016; and
ND kept; Saliva Hormone Testing (ND had own policy as non-covered); and
Dynamic Posturography (ND had BCBSA policy as non-covered); and
Diagnosis and Management of Idiopathic Environmental Intolerance - Clinical Ecology (ND using BCBSA policy) are included.

Internal Medical Policy Committee 11-19-2020

Removed: 2 exclusions from E/I section; and
Removed: Procedure codes 31627 & 43499.

Internal Medical Policy Committee 5-20-2021

Added: Procedure code S2107 as E/I.

Internal Medical Policy Committee 11-23-2021 Revision

Updated clarifying language

Internal Medical Policy Committee 5-24-2022 Revision with coding update

Added: Procedure code 93998

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Removed procedure code 81506; and
Removed Outpatient HCPCS (C Codes) and procedure code C9751; and
Updated references
Added Policy Application

Internal Medical Policy Committee 7-16-2024 Annual Review - no changes in criteria

Internal Medical Policy Committee 1-14-2025 Revision with coding update - Effective March 03, 2025

Added procedure code E1399; and
Added bullet under Not Medically Necessary section; and
Updated Policy Application; and
Updated references

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: Z-24-112

Section: Miscellaneous

Effective Date: January 01, 2020

Revised Date: March 04, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Archived Date: March 02, 2024

Applies To: Commercial and Medicaid Expansion

Description

This policy addresses those services considered to be miscellaneous and are typically not covered services.

Criteria

ALL services on this policy are non-covered for ONE of the following reasons:

The service is considered not medically necessary because it does not meet the definition of medical necessity; or
The service is a program exclusion/not a benefit; or

Not Medically Necessary

The following services are considered not medically necessary:

Anal fistula plug
Carbon monoxide, expired gas analysis (e.g., ETCO/hemolysis breath test)
Cellular function assay involving stimulation (e.g., mitogen or antigen) and detection of biomarker (e.g., ATP) (ImmuKnow®)
Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
Ferriscan
Idiopathic Environmental Intolerance - treatment and testing (e.g., intracellular analysis of micronutrients, ALCAT, IVIg)
Multivariate analysis of individual-specific findings with quantifiable computer probability assessment, including report
Neuro-selective current perception threshold (CPT/SNCT)Sensory Nerve Conduction Test
Outpatient intravenous insulin treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or arterial, venous, or capillary glucose; and/or potassium concentration
pH; exhaled breath condensate
Posturography (dynamic or static)
PreDx (Diabetes Risk Score)
Saliva test, hormone level; to assess preterm labor
Saliva test, hormone level; during menopause
Tenotomy of elbow, lateral or medial (e.g., epicondylitis, tennis elbow, golfer's elbow; percutaneous)
Thromboxane metabolite(s), including thromboxane if performed, urine
Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress urinary incontinence
InfraScanner Handheld Brain Hematoma Screening System For Early Detection of Intracranial Hemorrhage (ICH)
Defecography
Grenz Ray Therapy
Hair analysis
Lixiscope Service

Procedure Codes

24357

29999

46707

53860

74270

76498

77499

83987

84431

84999

86352

92548

92549

93998

99199

G0255

G9147

P2031

S2107

S2300

S3650

S3652

Program Exclusion/Not a Benefit

A program exclusion/not a benefit is defined as EITHER ONE of the following:

Services generally not covered under the specified program(s); or
Groups define benefits, and determine coverage

The following services are considered a program exclusion/not a benefit, and therefore non-covered:

Casted impressions for special shoes
EROS-Clitoral Therapy Device as a treatment of female sexual dysfunction
Hearing aid evaluation
Recreational or educational therapy (inpatient)

Procedure Codes

92590

92591

92592

92593

92594

92595

A9270

S0395

Medically Necessary

Procedure Code

93702

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 All four (4) of these policies :

Thermal Capsulorrhaphy for Joint Instability (BCBSA archived March 2016; and
ND kept; Saliva Hormone Testing (ND had own policy as non-covered); and
Dynamic Posturography (ND had BCBSA policy as non-covered); and
Diagnosis and Management of Idiopathic Environmental Intolerance - Clinical Ecology (ND using BCBSA policy) are included.

Internal Medical Policy Committee 11-19-2020

Removed: 2 exclusions from E/I section; and
Removed: Procedure codes 31627 & 43499.

Internal Medical Policy Committee 5-20-2021

Added: Procedure code S2107 as E/I.

Internal Medical Policy Committee 11-23-2021 Revision

Updated clarifying language

Internal Medical Policy Committee 5-24-2022 Revision with coding update

Added: Procedure code 93998

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Internal Medical Policy Committee 1-16-2024 Revision - Effective March 04, 2024

Removed procedure code 81506; and
Removed Outpatient HCPCS (C Codes) and procedure code C9751; and
Updated references
Added Policy Application

Internal Medical Policy Committee 7-16-2024 Annual Review - no changes in criteria

Medical Policies Quick Search

Miscellaneous Services

Description

Policy Application

Criteria

Not Medically Necessary

Procedure Codes

Program Exclusion/Not a Benefit

Procedure Codes

Medically Necessary

Policy Application

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Not Medically Necessary

Procedure Codes

Program Exclusion/Not a Benefit

Procedure Codes

Medically Necessary

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer