This policy addresses those services considered to be miscellaneous and are typically not covered services.
ALL services on this policy are non-covered for ONE of the following reasons:
The following services are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature:
Not Medically Necessary
The following services are considered not medically necessary:
Program Exclusion/Not a Benefit
A program exclusion/not a benefit is defined as EITHER ONE of the following:
The following services are considered a program exclusion/not a benefit, and therefore non-covered:
No Professional Service Rendered
When no professional service is rendered the service does not require direct patient care or contact.
The following services are considered no professional service rendered, and therefore non-covered:
Outpatient HCPCS (C Codes)