CC.PP.500

3 Day Payment Window

All hospitals (other than non-IPPS hospitals) are subject to a 3-day bundling requirement when they furnish preadmission diagnostic services to a member on the date of the inpatient admission or within 3 calendar days prior to the date of the inpatient admission, or when they furnish preadmission non-diagnostic services that are related to the member’s inpatient admission, on the date of the inpatient admission or within 3 calendar days prior to the date of the inpatient admission.

Marketplace

CC.PP.501

30 Day Readmission

All hospital claims submitted for a plan member that qualify as a readmission within 30 days of a discharge from the same hospital or a related hospital are subject to clinical review.

Marketplace

CC.PP.068

Multiple Procedure Payment Reduction for Therapeutic Services

When multiple (two or more) ‘always therapy’ procedures with an MPI of 5 are performed by the same provider, or by providers within the same group practice, on the same day, the policy will allow 100% of the maximum allowance for the therapeutic procedure with the highest cost per until and 90% of the allowance for each subsequent therapeutic procedure.

Marketplace

CP.MP.124

ADHD Assessment and Treatment

Outlines the types of ADHD assessments and treatments that are considered medically necessary.

Marketplace

CP.MP.100

Allergy Testing

Medical necessity guidelines for allergy testing and therapy.

Marketplace

CP.MP.96

Ambulatory EEG

Allows for ambulatory EEGs following an inconclusive or nondiagnostic standard EEG for indications outlined in the policy.

Marketplace

CP.MP.105

Digital EEG Analysis

Digital EEG spike analysis is considered medically necessary for members who have intractable epilepsy with a need for presurgical evaluation.

Marketplace

CP.MP.121

Homocysteine Testing

Homocysteine testing is considered medically necessary for the following indications: borderline vitamin B12 deficiency, homocystinuria caused by cystathionine beta-synthase deficiency, or Idiopathic venous thromboembolism, recurrent venous thromboembolism, thrombosis occurring at less than 45 years of age, or thrombosis at an unusual site.

Marketplace

CC.PP.065

Multiple Diagnostic Cardiovascular Procedure Payment Reduction

This policy is based on CMS reimbursement methodologies for MPPR and applies a multiple diagnostic cardiovascular procedure reimbursement reduction (MDCR) to procedures assigned a multiple procedure indicator (MPI) of 6 on the CMS National Physician Fee Schedule (NPFS). When this occurs, only the highest-valued procedure is reimbursed at the full payment allowance (100%) and payment for subsequent procedures/units is reimbursed at 75% of the allowance.

Marketplace

CP.MP.157

Vitamin D Testing in Children

Although a 25-hydroxyvitamin D concentration, reflecting both vitamin D synthesis and intake, is the correct screening lab to monitor for vitamin D deficiency, is not necessary or safe because current evidence when testing otherwise healthy children who are overweight or obese is not sufficient.

Marketplace

CP.MP.110

Bronchial Thermoplasty

Codes 31660 and 31661 are considered not medically necessary because the long-term safety and effectiveness has not been proven.

Marketplace

CP.MP.123

Laser Skin Treatment

Excimer laser skin based phototherapy (CPT codes 96920, 96921, and 96922) is considered medically necessary when it is submitted with one of the above ICD-10 diagnosis codes.

Marketplace

CP.MP.155

EEG in the Evaluation of Headache

EEGs are considered not medically necessary in the routine evaluation of a headache.

Marketplace

CP.MP.134

Evoked Potentials

Outlines medical necessity criteria for evoked potential testing.

Marketplace

CP.MP.153

H Pylori Testing

Code 86677 will not be paid because it is not medically necessary.

Marketplace

CP.MP.113

Holter Monitors

Holter Monitoring (CPT codes 93224, 93225, 93226, and 93227) is considered medically necessary for adult and pediatric members who require 24 to 48 hours of cardiac activity monitoring with any of the indications listed below (see policy summary).

Marketplace

CC.PP.050

Robotic Surgery

Code S2900 will not be paid because it is an add-on code billed in addition to the primary surgical procedure code and it denotes separate reimbursement for the robotic technique.

Marketplace

CP.MP.154

Thyroid Testing in Pediatrics

Deny thyroid function tests and insulin level testing in healthy, or obese but otherwise healthy, children 1-18 years of age. This is because slightly elevated levels of TSH in obesity are more likely a consequence of obesity than true hypothyroidism and there are significant limitations in the use of insulin levels as a marker of insulin resistance.

Marketplace

CP.MP.98

Urodynamic Testing

Urodynamic testing is medically necessary to assist in the diagnosis of urologic dysfunction with any of the indications outlined in the policy.

Marketplace

CC.PP.502

Wheelchair Accessories

Special wheelchair accessories are allowed based on the the indications outlined in the policy.

Marketplace

CP.MP.99

Wheelchair Seating

Special wheelchair seating cushions are medically necessary for the indications outlined in the policy.

Marketplace

CP.MP.143

Wireless Motility Capsule

Code 91112 will not be paid because it is investigational and not medically necessary.

Marketplace