Billing chart: Blue Cross highlights medical, benefit policy changes

0404T

Other codes:
58674, 58578,** 58999**

Basic benefit and medical policy

Myolysis of uterine fibroids – Sonata^® added

Laparoscopic or transcervical ultrasound-guided radiofrequency ablation (e.g., Acessa™ or Sonata^® System™) for the treatment of uterine fibroids is established. It may be considered a useful therapeutic option when indicated.

Laparoscopic and percutaneous techniques of myolysis as a treatment of uterine fibroids other than laparoscopic ultrasound-guided radiofrequency ablation (e.g., Acessa™) and transcervical ultrasound-guided radiofrequency ablation (e.g., Sonata^® System) are considered experimental, including Nd: YAG lasers, bipolar electrodes and cryomyolysis. There is insufficient published evidence to assess the safety and impact on health outcomes in the treatment of uterine fibroids.

This policy update is effective Sept. 1, 2021.

Inclusions:

Laparoscopic or transcervical ultrasound-guided radiofrequency ablation (e.g., Acessa™ or Sonata^® System™)

Laparoscopic or transcervical ultrasound-guided radiofrequency ablation for the treatment of uterine fibroids may be indicated as an alternative to hysterectomy or myomectomy when the member has one or more of the following:

• Evidence of uterine fibroids via ultrasound that are less than 10 cm in diameter for Acessa™ or 7 cm for Sonata™
• Pre-menopausal state with symptomatic fibroids in members who want to avoid a hysterectomy
• Members who have contraindications to general anesthesia
• Members who have experienced any of the following symptoms that are the direct result of the fibroids:
1. Severe menorrhagia causing anemia
2. Bulk-related symptoms (e.g., pelvic pain, pressure or discomfort, urinary symptoms related to compression of the ureter or bladder, or dyspareunia)

Exclusions:

Laparoscopic or transcervical ultrasound-guided radiofrequency ablation (e.g., Acessa™ or Sonata^® System™) for all situations other than those specified above, and not limited to the conditions below:

• When there has been a diagnosis of cancer (or pre-cancerous lesions) anywhere in the pelvis
• In members who are diagnoses with or at risk for leiomyosarcoma
• In members with acute pelvic inflammatory disease
• In members with abnormal pap smear test results
• In members who are in a post-menopausal state
• Pedunculated fibroid type 0 or type 7 for the Sonata^® System™

15833, 15836, 15878, 15879, 38589,**
38999**

**Unlisted codes used to report primary surgical procedure

Not covered procedures:
49329, 49999

Basic benefit and medical policy

Surgical treatments for lymphedema

Lymphovenous bypass and vascularized lymph node transplant for lymphedema may be considered established as a therapeutic option when indicated.

Surgical treatment of massive localized lymphedema and late-stage lymphedema by liposuction or excision is considered established.

The policy effective date is March 1, 2021.

Inclusions:

Lymphovenous bypass and vascularized lymph node transplant may be considered as surgical options when the following criteria are met:

1. Signs and symptoms consistent with lymphedema as determined by a certified lymphedema therapist, and
2. A diagnosis of stage ≥ I lymphedema by the International Society of Lymphology, or ISL, standards, and
3. For lymphovenous bypass for unilateral disease, at least one of the following positive quantitative measurements:
1. MR lymphangiogram demonstrating residual lymphatic channels
2. Lymphoscintigraphy findings showing a minimum of a one-hour delayed transit time to first-level lymph nodes, axillary lymph nodes (upper extremity lymphedema) or inguinal lymph nodes (lower extremity lymphedema), or a dermal back flow pattern
3. Volumetry differential (circumferential measurements and/or perometry differential) >10% (if affected extremity dominant extremity) or >7% (affected extremity is non-dominant extremity),
4. Bioimpedance abnormality differential consistent with lymphedema

4. Patients with bilateral disease should meet A, B, and C-1 or C-2, above. 
5. For vascularized lymph node transfer, at least one of the following:
1. MR lymphangiogram showing absence of lymphatic channels
2. Lymphoscintigraphy findings showing a minimum of a one-hour delayed transit time to first-level lymph nodes, axillary lymph nodes (upper extremity lymphedema) or inguinal lymph nodes (lower extremity lymphedema), or a dermal back flow pattern 
3. Volumetry differential (circumferential measurements and/or perometry differential >10% (if affected extremity dominant extremity) or >7% (affected extremity is non-dominant extremity),
4. Bioimpedance abnormality differential consistent with lymphedema.

6. Patient also meets all the following eligibility criteria:
1. Patient has body mass index ≤ 35-40kg/m2 
2. Patient has undergone a course of conservative treatment under the supervision of a lymphedema therapist
3. Patient has demonstrated the ability to tolerate post-surgical compression therapy and physical therapy sessions per treating lymphedema provider.

7. None of the following are present:
1. Chronic venous disease (e.g., chronic venous insufficiency, superior vena cava syndrome) 
2. Congestive heart failure
3. Medication-induced swelling
4. Liver disease including, but not limited to, cirrhosis, hypoproteinemia  v. nephropathy including end-stage renal disease
5. Active infection of the affected extremity (cellulitis/erysipelas)
6. History of dye anaphylaxis 

8. Microsurgery for lymphedema is performed by surgeons with specialized training in lymphedema surgery and lymphology.

Exclusions:

• Lymph node transplant or lymphovenous bypass is considered experimental if the above criteria aren’t met.
• Debulking of a limb not impacted by lymphedema or lipedema is considered experimental if the above criteria aren’t met.
• Greater omental lymph node flap is considered experimental.
• Lymphatic microsurgical preventing healing approach (Lympha) is considered experimental.

Note: Refer to Table 1 for staging of lymphedema.

Table 1. Recommendations for staging lymphedema

15271-15278, 15777, Q4100-Q4108,
Q4110, Q4114, Q4116-Q4118, Q4121, Q4122, Q4124, Q4127, Q4128, Q4130, Q4135, Q4136, Q4147, Q4149, Q4158, Q4161, Q4164-Q4166, Q4182, Q4195, Q4196, Q4203, A6010, A6011, A6021-A6023, C9356, C9358, C9360, C9363, C9364  

Experimental:
Q4111-Q4113, Q4115, Q4123, Q4125,
Q4126, Q4134, Q4141-Q4143, Q4146,
Q4152, Q4167, Q4175-Q4180, Q4193,
Q4197, Q4200, Q4202, Q4220, Q4222,
Q4226, Q4238

Basic benefit and medical policy

Skin and tissue substitutes

The safety and effectiveness of skin and tissue substitutes approved by the U.S. FDA and the Centers for Medicare & Medicaid Services have been established for patients meeting specified selection criteria. They may be useful therapeutic options when indicated.

Human tissue products are subject to the rules and regulations of banked human tissue by the American Association of Tissue Banks, or AATB, and have been established for patients meeting specified selection criteria. They may be useful therapeutic options when indicated.

This policy has been updated, effective Nov. 1, 2021.

Inclusions:

The following skin and tissue substitutes are considered established as they have been approved by the FDA. This list may not be all-inclusive:

• Apligraft^®
• Atlas Wound Matrix
• Biobrane^®
• Bio-conneKt^® Wound Care Matrix
• Cytal^® Burn Matrix
• Cytal^® MicroMatrix™
• Cytal™ Wound Matrix (formerly MatriStem)
• Cytal^® Wound Sheet
• Derma-Gide (aka Geistlich Derma-Gide™)
• Dermagraft^®
• Endoform Dermal Template™
• Epicel^® has FDA humanitarian device spproval
• E-Z Derm™
• Helicoll™
• Hyalomatrix^®
• Integra^® Bilayer Matrix
• Integra^® Dermal Regeneration Template
• Integra^® Flowable Wound Matrix
• Intregra^® Matrix Wound Dressing (formerly known as Avagen)
• Keratec Wound Dressings (Kermatrix^®):
• Keratec Keragel
• Keraderm
• Kerafoam
• Kerecis™ Omega3 Wound (formerly known as MeriGen)
• MediSkin^®
• MicroMatrix^®
• Oasis^® Burn Matrix
• Oasis^® Ultra Tri-Layer Wound Matrix
• Oasis^® Wound Matrix
• Ologen™ Collagen Matrix
• OrCel^®
• Permacol™ (Covidien)
• PriMatrix™
• Puracol^® and Puracol^® Plus Collagen Wound Dressings
• PuraPly Wound Matrix (PuraPly)
• PuraPly Antimicrobial Wound Matrix (PuraPly AM)
• Strattice™
• Suprathel^®
• SurgiMend^®
• Talymed™
• TenoGlide™
• TheraSkin^®
• TransCyte^®

Breast reconstructive surgery using allogeneic acellular dermal matrix products (including each of the following: AlloDerm^®, AlloMend^®, Cortiva^®, [AlloMax™], DermACELL™, DermaMatrix™, FlexHD^®, FlexHD^® Pliable™, Graftjacket^®) are considered established when one of the following is met:

• There’s insufficient tissue expander or implant coverage by the pectoralis major muscle and additional coverage is required.
• There’s viable but compromised or thin postmastectomy skin flaps that are at risk of dehiscence or necrosis.
• The inframammary fold and lateral mammary folds have been undermined during mastectomy and reestablishment of these landmarks is needed.

Note: Various acellular dermal matrix products used in breast reconstruction have similar efficacy. The products listed are those that have been identified for use in breast reconstruction. Additional acellular dermal matrix products may become available for this indication.

Treatment of chronic, noninfected, full-thickness diabetic lower extremity ulcers is established when using the following tissue engineered skin substitutes:

• AlloPatch^®a
• Apligraft^®b
• Dermagraft^®b
• GraftJacket^® Regenerative Tissue Matrix-Ulcer Repair
• Integra^®, OmnigraftTM Dermal Regeneration Matrix (also known as Omnigraft™) and Integra Flowable Wound Matrix
• Theraskin^®

Treatment of chronic, noninfected, partial- or full-thickness lower-extremity skin ulcers due to venous insufficiency, which have not adequately responded following a one-month period of conventional user therapy is established when using the following tissue-engineered skin substitutes:

• Aplifraf^®b
• OasisTM Wound Matrix^c
• Theraskin^®

OrCel™ is considered established when all of the following criteria are met:

• Used for the treatment of dystrophic epidermolysis bullosa
• Used for the treatment of mitten-hand deformity
• Standard would therapy has failed
• Provided in accordance with the humanitarian device exemption, or HDE, specifications of the FDA

The following skin and tissue products and substitutes are considered established for use in the treatment of second- and third-degree burns:

• Alloderm
• Epicel^® (for the treatment of deep dermal or full-thickness burns comprising a total body surface area ≥30% when provided in accordance with the HDE specifications of the FDA)^d
• Integra^® Dermal Regeneration Template^b

^aBanked human tissue
^bFDA premarket approval
^cFDA 510(k) clearance
^dFDA-approved under an HDE

Exclusions:

All other uses of bioengineered skin and soft tissue substitutes listed above unless they meet the following criteria:

• FDA approval and provided in accordance with the FDA guidelines
• Covered by Centers for Medicare & Medicaid Services

All other skin and soft tissue substitutes, including but not limited to:

• ACell^® UBM Hydrated/Lyophilized Wound Dressing
• AlloSkin™
• AlloSkin™ RT
• Aongen™ Collagen Matrix
• Architect^® ECM, PX, FX
• ArthroFlex™ (Flex Graft)
• AxoGuard^® Nerve Protector (AxoGen)
• BellaCell HD or SureDerm^®
• CollaCare^®
• CollaCare^® Dental
• Collagen Wound Dressing (Oasis Research)
• CollaGUARD^®
• CollaMend™
• CollaWound™
• Coll-e-Derm
• Collexa^®
• Collieva^®
• Conexa™
• Coreleader Colla-Pad
• CorMatrix^®
• Cymetra™ (Micronized AlloDerm™)
• Dermadapt™ Wound Dressing
• DermaPure™
• DermaSpan™
• DressSkin
• Durepair Regeneration Matrix^®
• ENDURAGen™
• Excellagen
• ExpressGraft™
• FlexiGraft^®
• FlowerDerm^®
• GammaGraft
• Graftjacket^® Xpress, injectable
• hMatrix^®
• InteguPly^®
• Keramatrix^®
• Keroxx™
• MatriDerm^®
• Matrix HD™
• MemoDerm™
• Microderm^® biologic wound matrix
• Miroderm^®
• MyOwn Skin™
• NeoForm™
• Progenamatrix™
• Puros^® Dermis
• RegenePro™
• Repliform^®
• Repriza™
• Restrata
• SkinTE™
• StrataGraft^®
• TenSIX™ Acellular Dermal Matrix
• TissueMend
• TheraForm™ Standard/Sheet
• TruSkin™
• Veritas^® Collagen Matrix
• XCM Biologic^® Tissue Matrix
• XenMatrix™ AB

47133, 47135, 47140, 47141, 47142, 47143, 47144, 47145, 47146, 47147, 47399

Basic benefit and medical policy

Liver transplant

The safety and effectiveness of liver transplantation and retransplantation have been established. It may be considered a useful therapeutic procedure in carefully selected patients with end-stage liver failure due to irreversibly damaged livers.

Exclusionary criteria have been updated, effective Nov. 1, 2021.

Inclusionary and exclusionary guidelines:

Inclusions for liver transplant:
           

• Patients with end-stage liver disease. Etiologies of end-stage liver disease include, but are not limited to, the following:
1. Hepatocellular diseases
• Alcoholic liver disease
• Viral hepatitis (either A, B, C, or non-A, non-B)
• Autoimmune hepatitis
• Alpha-1 antitrypsin deficiency
• Hemochromatosis
• Non-alcoholic steatohepatitis
• Protoporphyria
• Wilson's disease
2. Cholestatic liver diseases
• Primary biliary cirrhosis
• Primary sclerosing cholangitis with development of secondary biliary cirrhosis
• Biliary atresia
3. Vascular disease
• Budd-Chiari syndrome
4. Neuroendocrine tumors metastatic to the liver*** (see NET criteria below)
5. Primary hepatocellular carcinoma
6. Inborn errors of metabolism
7. Trauma and toxic reactions
8. Miscellaneous indications
• Familial amyloid polyneuropathy
• Patients with polycystic disease of the liver who have massive hepatomegaly causing obstruction or functional impairment.
• Pediatric patients with nonmetastatic hepatoblastoma
• Patients with unresectable hilar cholangiocarcinoma if additional inclusionary criteria are met (see below)**

**Cholangiocarcinoma (Available online at:
https://optn.transplant.hrsa.gov/)

According to the OPTN policy on liver allocation, candidates with cholangiocarcinoma, or CCA, meeting the following criteria will be eligible for a MELD/PELD exception with a 10% mortality equivalent increase every three months:

• Centers must submit a written protocol for patient care to the OPTN/UNOS Liver and Intestinal Organ Transplantation Committee before requesting a MELD score exception for a candidate with CCA. This protocol should include selection criteria, administration of neoadjuvant therapy before transplantation, and operative staging to exclude patients with regional hepatic lymph node metastases, intrahepatic metastases, or extrahepatic disease. The protocol should include data collection as deemed necessary by the OPTN/UNOS Liver and Intestinal Organ Transplantation Committee.
• Candidates must satisfy diagnostic criteria for hilar CCA:** malignant-appearing stricture on cholangiography and one of the following: carbohydrate antigen 19-9 100 U/mL, or a biopsy or cytology results demonstrating malignancy, or aneuploidy. The tumor should be considered unresectable on the basis of technical considerations or underlying liver disease (e.g., primary sclerosing cholangitis).
• If cross-sectional imaging studies (CT scan, ultrasound, MRI) demonstrate a mass, the mass should be 3 cm or less.
• Intra- and extrahepatic metastases should be excluded by cross-sectional imaging studies of the chest and abdomen at the time of initial exception and every three months before score increases.
• Regional hepatic lymph node involvement and peritoneal metastases should be assessed by operative staging after completion of neoadjuvant therapy and before liver transplantation. Endoscopic ultrasound-guided aspiration of regional hepatic lymph nodes may be advisable to exclude patients with obvious metastases before neoadjuvant therapy is initiated.
• Transperitoneal aspiration or biopsy of the primary tumor (either by endoscopic ultrasound, operative or percutaneous approaches) should be avoided because of the high risk of tumor seeding associated with these procedures.

***Criteria for liver transplant patient selection for neuroendocrine tumors, or NET, metastatic to the liver (MELD exception applications for patients with NET):

1. Recipient age <60 years
2. Resection of primary malignancy and extra-hepatic disease without any evidence of recurrence at least six months prior to MELD exception request.
3. Liver-limited neuroendocrine liver metastasis, or NLM, bi-lobar, not amenable to resection. Tumors in the liver should meet the following radiographic characteristics:
1. CT scan: Triple phase contrast:
1. Lesions may be seen on only one of the three phases
2. Arterial phase: may demonstrate a strong enhancement
3. Large lesions can become necrotic/calcified
2. MRI appearance:
1. Liver metastasis are hypodense on T1 and hypervascular in T2 wave images
2. Diffusion restriction
3. Majority of lesions are hypervascular on arterial phase with wash – out during portal venous phase IV. Hepatobiliary phase post Gadoxetate Disodium (Eovist): Hypointense lesions are characteristics of NET
4. Consider for exception only those with a NET of Gastro-entero-pancreatic, or GEP, origin tumors with portal system drainage. Note: Neuroendocrine tumors with the primary located in the lower rectum, esophagus, lung, adrenal gland or thyroid aren’t candidates for automatic MELD exception.
5. Lower-intermediate grade following the WHO classification. Only well differentiated (low grade, G1) and moderately differentiated (intermediate grade G2). Mitotic rate <20 per 10 HPF with less than 20% ki-67 positive markers
6. Tumor metastatic replacement shouldn’t exceed 50% of the total liver volume
7. Negative metastatic workup should include one of the following:
• Positron emission tomography (PET scan)
• Somatostatin receptor scintigraphy
• Gallium-68 (68Ga) labeled somatostatin analogue 1,4,7,10-tetraazacyclododedcane-N, N′, N″,N′″-tetraacetic acid (DOTA)-D-Phe1-Try3–octreotide (DOTATOC) or other scintigraphy to rule out extra-hepatic disease, especially bone metastasis.

Note: Exploratory laparotomy and or laparoscopy isn’t required prior to MELD exception request.

8. No evidence for extra-hepatic tumor recurrence based on metastatic radiologic workup at least three months prior to MELD exception request (submit date)
9. Recheck metastatic workup every three months for MELD exception increase consideration by the Regional Review Board. Occurrence of extra-hepatic progression – for instance lymph-nodal Ga68 positive locations – should indicate de-listing. Patients may come back to the list if any extra-hepatic disease is zeroed and remained so for at least six months.
10. Presence of extra-hepatic solid organ metastases (e.g., lungs, bones) should be a permanent exclusion criteria.

Exclusions for liver transplant:

• Patients with intrahepatic cholangiocarcinoma
• Patients with hepatocellular carcinoma that has extended beyond the liver
• Patients with ongoing alcohol or drug abuse. (Evidence for abstinence may vary among liver transplant programs, but generally, a minimum of three months is required.)
• Patients with conditions not included in the inclusions section:
  • Severe cardiac or pulmonary disease
  • AIDS
  • Uncontrolled sepsis
  • Anatomic abnormality that precludes liver transplantation Intrahepatic cholangiocarcinoma
  • Extrahepatic malignancy
  • Hemangiosarcoma
  • Persistent noncompliance

Inclusions for liver retransplant:

 Liver retransplant is established for patients with:

• Primary graft non-function
• Hepatic artery thrombosis
• Chronic rejection
• Ischemic type biliary lesions after donation after cardiac death
• Recurrent non-neoplastic disease-causing late graft failure

Exclusions for liver retransplant:

Patients not meeting above inclusionary criteria for retransplant.

Potential contraindications for transplant or retransplant:

Note: Final patient eligibility for transplant is subject to the judgment and discretion of the requesting transplant center.

Potential contraindications represent situations where proceeding with transplant isn’t advisable in the context of limited organ availability. Contraindications may evolve over time as transplant experience grows in the medical community. Clinical documentation supplied to the health plan should demonstrate that attending staff at the transplant center have considered all contraindications as part of their overall evaluation of potential organ transplant recipients and have decided to proceed.

• Known current malignancy or history of recent malignancy
• Untreated systemic infection making immunosuppression unsafe, including chronic infection
• Other irreversible end-stage disease not attributed to liver disease
• Systemic disease that could be exacerbated by immunosuppression
• Psychosocial conditions or chemical dependency affecting ability to adhere to therapy as defined by the transplant program

Established:

81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81307, 81308, 81317, 81318, 81319, 81401, 81403, 81406, 81435, 81436, 81445, 81450

Experimental:

Basic benefit and medical policy

Genetic cancer susceptibility panels

The medical policy statement, and inclusionary and exclusionary criteria have been updated, effective Nov. 1, 2021.

Medical policy statement:

Limited genetic cancer susceptibility panels that include only gene variants for which the member meets criteria in other policies may be considered established (see related policies for the Inclusionary and Exclusionary Guidelines).

Genetic cancer susceptibility panel testing is considered experimental in all other situations.

Reference the following policies for specific coverage criteria:

• Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome (BRCA1 or BRCA2)
• Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
• Genetic Testing (Single Nucleotide Variants) To Predict Risk of Nonfamilial Breast Cancer
• Gene Expression Profiling for Cutaneous Melanoma
• Gene Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk
• Moderate Penetrance Variants Associated with Breast Cancer in Individuals at High Breast Cancer Risk
• Circulating Tumor DNA Management of Non-Small-Cell Lung Cancer (Liquid Biopsy)
• Genetic Testing for PTEN Hamartoma Tumor Syndrome
• Genetic Testing-NGS Testing of Multiple Genes (Panel) to Identify Targeted Cancer Therapy

81401, 81405, 81408, 81410, 81411,
81479**

Basic benefit and medical policy

Genetic testing for connective tissue disorders and thoracic aortic aneurysms

The safety and effectiveness of genetic testing for Marfan syndrome, Ehlers-Danlos syndrome type IV (vascular type), other syndromes associated with thoracic aortic aneurysms and dissections, and related disorders have been established. It may be considered a useful diagnostic option when indicated.

The inclusionary criteria and policy title have been updated, effective Nov. 1, 2021.

Inclusions:

Individual genetic testing for the diagnosis of Marfan syndrome, Ehlers-Danlos syndrome type IV (vascular type), other syndromes associated with thoracic aortic aneurysms and dissections, and related disorders when:

• Focused genetic testing of the following genes: FBN1, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK, TGFBR1 and TGFBR2 or
• A panel of at least nine genes that must include FBN1, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK, TGFBR1 and TGFBR2 when one of the following is met:
• Signs and symptoms of a connective tissue disorder are present, but a definitive diagnosis can’t be made using established clinical diagnostic criteria (i.e., Ghent criteria)
• Assessing future risk of disease in an asymptomatic individual when there is a known pathogenic variant in the family.

Exclusions:

• Genetic testing panels for Marfan syndrome, Ehlers-Danlos syndrome type IV (vascular type), other syndromes associated with thoracic aortic aneurysms and dissections, and related disorders that don’t include genes listed under inclusions
• For the prenatal or pre-implantation genetic diagnosis of Marfan syndrome in the offspring of patients with known disease-causing variants

Covered services:

Online codes:
98970-98972, 99421-99423

Telephone codes:
99441-99443, 98966 98968

Any code that is appropriate for both the encounter and provider scope, (including behavioral health not related to autism) and is delivered synchronously (in real time)

Asynchronous care:
99446, 99447, 99448, 99449, 99451, 99452

Any code that is appropriate for both the encounter and provider scope and is delivered asynchronously

Behavioral health services: There are multiple billing codes for behavioral health services; behavioral health services aren’t appropriate for asynchronous care.

Basic benefit and medical policy

Telemedicine services

Medical

The safety and effectiveness of telemedicine (synchronous and asynchronous care) for medical care have been established. It may be considered a useful diagnostic and therapeutic option when indicated.

Behavioral health

The safety and effectiveness of telemedicine synchronous care for behavioral health have been established, with the exception of specific autism services.**

Telemedicine asynchronous care isn’t appropriate for behavioral health services.

**Refer to the policy “Autism Spectrum Disorder Services.”

The exclusionary criteria have been updated, effective Nov. 1, 2021.

Payment policy:

Behavioral health services may require prior authorization. Procedure codes *96130 and *96156 aren’t eligible telemedicine services.

Inclusions:

Synchronous/real-time encounter:

• The provider must be licensed, registered or otherwise authorized to perform service in their health care profession in the state where the patient is located. Services must fall within their scope of practice.
• Telemedicine delivered services are available to all clinicians; however, this may not be the preferred method of delivery in certain clinical scenarios, for example chronic suicidal ideation or unstable angina. A hosted visit** or a face-to-face visit may be necessary due to the complexity of the clinical situation. The telemedicine provider may provide the face-to-face encounter.
• Telemedicine delivered services for ongoing treatment of a condition that is chronic or is expected to take more than five sessions before the condition resolves or stabilizes may require a hosted visit** or a face-to-face visit. The telemedicine provider may provide the face-to-face encounter.
• The service must be conducted over a secured channel.
• The delivery of the service can be either audio only (telephone) or audio/video (a secured computer-based system). 

Online visit:

• An audiovisual online communication
• The patient initiates the medical or behavioral health encounter
• The provider must be licensed, registered or otherwise authorized to perform service in their health care profession in the state where the patient is located.
• A low complexity, straight forward decision-making encounter that addresses urgent but not emergent clinical conditions
• A single encounter where a follow-up encounter isn’t anticipated
• Services must fall within the provider’s scope of practice.

Asynchronous/store and forward encounter:

• The provider must be licensed, registered or otherwise authorized to perform service in their health care profession in the state where the patient is located. Services must fall within their scope of practice.
• The patient data (pre-recorded videos, digital images such as X-rays or photos, test results or any other information necessary for the evaluation) must be transmitted over a secured channel.

Exclusions:

Synchronous and asynchronous:

• Request for medication refills
• Reporting of normal test results
• Provision of educational materials
• Scheduling of appointments and other health care related issues
• Registration or updating billing information
• Reminders for health care related issues
• Referrals to other providers
• An online or telemedicine visit resulting in an office visit, urgent care or emergency care encounter on the same day for the same condition
• An online visit for the same condition of an online visit within the previous seven days
• An online or telemedicine visit occurring during the post-operative period

Behavioral health care:

Behavioral health care services may be delivered via synchronous telemedicine, including intensive outpatient program, or IOP, and partial hospital program, or PHP, services. 

Behavioral health-specific synchronous care exclusions:

Autism services are allowed via telemedicine synchronous care, but with limitations and exceptions. Refer to the policy “Autism Spectrum Disorder Services.”

Behavioral health-specific asynchronous care exclusions:

Behavioral health services aren’t appropriate via telemedicine asynchronous care.  

Note: See policy guidelines and billing guidance sections of the medical policy for more information.