Policy regarding infusion of substances considered not medically necessary by BCBSM

BCBSM carefully considers whether procedures, services, substances, treatments and medications are deemed medically necessary. BCBSM has determined that certain infused substances do not meet our standards of medical necessity; therefore, you may not submit claims for these substances.

Examples of these types of infused substances include: Meyer’s solution or other homeopathic medicines, “mega” doses of vitamins and vitamin B12 in patients without documented B12 deficiency.

When you infuse substances that we consider not medically necessary, you may not submit claims for related infusion services, for example, CPT codes *96365 and *96366.

In addition, if you employ systems of care using diagnostic and treatment methods that we consider not medically necessary, you may not submit claims for services provided in this context, even if the same services would be payable in the context of a medically necessary treatment plan. Examples of services that are not payable in this situation include laboratory testing and evaluation and management services.

If you are a BCBSM-contracted health care provider and intend to provide services to our members that we consider not medically necessary, you must notify our member before delivering the service that it is not covered by BCBSM. The member will be personally responsible for payment. BCBSM will not reimburse the member for these services.

If you do not inform your patient (our member) about noncovered proposed treatments, we will consider it a violation of our Traditional Participating Provider Agreement and our PPO TRUST Agreement. Violation of these contracts is grounds for termination of your BCBSM provider agreements.