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Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2014, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2014 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-95805-02

Original Effective Date: 11/15/01

Reviewed: 06/23/11

Revised: 05/11/14

Subject: Nerve Conduction Studies; F-Wave Studies; H- Reflex Studies

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates    

DESCRIPTION:

Electrodiagnostic medicine (EDX) is an extension of the clinical evaluation of patients with disorders of the peripheral or central nervous system. EDX studies are often crucial to evaluating symptoms, arriving at a proper diagnosis, and in following a disease process and its response to therapy in patients with neuromuscular disorders. EDX studies include the following:

This medical coverage guideline addresses nerve conduction studies (NCS), H-reflex studies, and F-wave studies.

Motor, sensory, and mixed NCSs and late responses (F-waves and H-reflex studies) are frequently complementary and performed during the same patient evaluation. Although the stimulation of nerves is similar across all NCSs, the characteristics of motor, sensory, and mixed NCSs are different. In each case, an appropriate nerve is stimulated and a recording is made either from appropriate nerves or from muscle supplied by the motor nerve.

F-wave and H-reflex studies are noninvasive assessments of the peripheral nervous system. The nerve trunk is stimulated and the response of the innervated muscle recorded. These studies evaluate the entire length of a nerve, from the spinal cord to innervated muscle.

H-reflex and F-wave testing detect proximal pathology in nerves that would not be detected by standard motor and sensory nerve conduction techniques, such as lesions at the nerve root level that can occur in cervical or lumbar radiculopathies or Guillian-Barre syndrome.

F-wave studies of a nerve are virtually never performed without a motor nerve conduction study of that nerve. F-wave studies assess motor nerve function along the entire extent of that nerve. Multiple F-wave studies may be performed on a patient during a given encounter. The number of F-wave studies required depends on the working diagnosis and the electro-diagnostic findings already in evidence. Frequently, two and sometimes more F-wave studies are needed. When F-wave studies are indicated on one limb, the same number of studies must be performed on the contralateral limb for comparison purposes. It is not unusual to perform four separate F-wave studies, two on the affected limb and two on the unaffected limb to serve as normal controls.

H-reflex studies involve both the sensory and motor nerves. They assess sensory and motor nerve function and their connections in the spinal cord. They usually involve assessment of the tibial motor nerve and the gastrocnemius-soleus muscle complex, and are not often performed in conjunction with conventional nerve conduction studies of this nerve-muscle pair. Typically, only one or two H-reflex studies are performed on a patient during a given encounter. Bilateral gastrocnemius-soleus H-reflex abnormalities are often early indications of spinal stenosis, bilateral S1 radiculopathies, and peripheral polyneuropathies. In rare instances, H-reflex studies are tested in muscles other than the gastrocnemius-soleus muscle, such as, in the upper limbs. In conditions such as cervical radiculopathies or brachial plexopathies, an H-reflex study can be performed in the arm (flexor carpi radialis muscle). Other muscles that may be tested, although rarely, are the intrinsic small muscles of the hand and foot.

Portable devices have been developed to provide point-of-care nerve conduction studies. These portable devices have computational algorithms that are able to drive stimulus delivery, measure and analyze the response, and provide a detailed report of study results. Automated nerve conduction could be used in various settings, including primary care, without the need for specialized training or equipment.

Point-of-care nerve conduction testing has also been proposed for the diagnosis of peripheral neuropathy and, in particular, for detecting neuropathy in patients with diabetes. Peripheral neuropathy is relatively common in patients with diabetes mellitus, and the diagnosis is often made clinically through the physical examination. Diabetic peripheral neuropathy can lead to important morbidity including pain, foot deformity, and foot ulceration. Clinical practice guidelines recommend using simple sensory tools such as the 10-g Semmes-Weinstein monofilament or the 128-Hz vibration tuning fork for diagnosis. These simple tests predict the presence of neuropathy defined by electrophysiological criteria with a high level of accuracy. Electrophysiological testing may be used in research studies and may be required in cases with an atypical presentation.

NC-stat® by NeuroMetrix is a portable nerve conduction test device designed to be used at the point-of-care. The system comprises a biosensor array, an electronic monitor, and a remote report generation system. The biosensor is a single use, preconfigured array consisting of a stimulation anode and cathode, skin surface digital thermometer, and response sensor. Biosensor arrays are available for assessment of sensory and motor nerves of the wrist (median and ulnar), and for the foot (peroneal, posterior tibial, and sural). A chip imbedded in the biosensor panel measures skin surface temperature, the analysis algorithm adjusts for differences in temperature from 30º C, or if skin surface temperature is less than 23º C the monitor will indicate that limb warming is necessary. Data are sent to a remote computer via a modem in the docking station, and the remote computer generates a report based on the average of 6 responses that is sent back by fax or email. In addition to the automated stimulus delivery and reporting, NC-stat analysis adjusts the calculation for body temperature, height, and weight, and uses the average of 6 responses. Sensitivity of the device for sensory nerve amplitude potentials is 2.1 µV, values lower than this are analyzed as zero, and responses with artifact are automatically eliminated from the analysis.

Several devices are now being marketed for point-of-care neural conduction testing. NeuroMetrix received specific clearance to market NC-stat® via the U.S. Food and Drug Administration’s (FDA) 510(k) process in 1998, listing as predicate devices the TECA model-10 electromyograph and the Neurometer by Neurotron, which measures vibration threshold. The FDA listed intended use was “to measure neuromuscular signals that are useful in diagnosing and evaluating systemic and entrapment neuropathies.” In addition, the approved application stated “The NC-stat is intended to be used as an adjunct to and not a replacement for conventional electrodiagnostic measurements.” NeuroMetrix subsequently received FDA clearance to market newer models with biosensors and engineering changes that enable the NC-stat to be used for motor and sensory nerves of the wrist (median and ulnar) and foot (peroneal, tibial, and sural). The intended use as listed on the 510(k) approval from 2006 (#K060584) is “to stimulate and measure neuromuscular signals that are useful in diagnosing and evaluating systemic and entrapment neuropathies”. The XLTek Neuropath (Excel-Tech) received clearance for marketing through the FDA’s 510(k) process in 2006; the indications are the same as those for NC-stat. The Neural-Scan™ NCS (Excite Medical) is a Class I diagnostic device (FDA clearance not usually required) that is being marketed ‘as part of the [sic] neurological examination or for screening to detect peripheral neuropathies.”

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request for Nerve Conduction Studies; F-Wave Studies; H- Reflex Studies to expedite the medical review process.

1. Click the link Nerve Conduction Studies; F-Wave Studies; H- Reflex Studies - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

When a therapeutic decision is based on test results, Nerve Conduction Studies (NCS) meet the definition of medical necessity when ALL of the following criteria are met:

There may be instances when a needle EMG is not typically performed in conjunction with nerve conduction studies. Nerve conduction studies performed alone (without a NEMG) meet the definition of medical necessity for the following situations:

Automated nerve conduction tests or portable hand-held non-invasive nerve conduction studies (e.g., NC-stat System, Brevio® nerve conduction monitoring system) are experimental or investigational because there is insufficient scientific data to permit conclusions regarding the effectiveness of these nerve conduction tests compared to conventional electrodiagnostic testing.

BILLING/CODING INFORMATION:

The following codes may be used to describe nerve conduction studies:

CPT Coding:

95885*

Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure)

95886*

Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure)

95887*

Needle electromyography, non-extremity (cranial nerve supplied or axial) muscle(s) done with nerve conduction amplitude and latency/velocity study (List separately in addition to code for primary procedure)

95905

Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report (investigational)

95907

Nerve conduction studies; 1-2 studies

95908

Nerve conduction studies; 3-4 studies

95909

Nerve conduction studies; 5-6 studies

95910

Nerve conduction studies; 7-8 studies

95911

Nerve conduction studies; 9-10 studies

95912

Nerve conduction studies; 11-12 studies

95913

Nerve conduction studies; 13 or more studies

CODING NOTES

Per CPT instruction:

Refer to Appendix J of the CPT code book for suggested nerve conduction studies for specific conditions and diagnoses.

HCPCS Coding:

G0453

Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure)

ICD-9 Diagnoses Codes That Support Medical Necessity:

250.60 – 250.63

Diabetes with neurological manifestations

335.0, 335.10, 335.11, 335.19, 335.20, 335.21, 335.22, 335.23, 335.24, 335.29, 335.8, 335.9

Anterior horn cell disease

337.20 – 337.29

Reflex sympathetic dystrophy

353.8

Other nerve root and plexus disorders

354.0

Carpal tunnel syndrome

354.0 – 354.9

Mononeuritis of upper limb and mononeuritis multiplex

355.0 – 355.6

Mononeuritis of lower limb

355.71 – 355.79

Other mononeuritis of lower limb

355.8 – 355.9

Mononeuritis of lower limb, unspecified and of unspecified site

356.0 – 356.9

Hereditary and idiopathic peripheral neuropathy

357.0 – 357.9

Inflammatory and toxic neuropathy

358.00 – 358.01

Myasthenia gravis

359.0 – 359.9

Muscular dystrophies and other myopathies

722.80 – 722.83

Postlaminectomy syndrome

723.1

Cervicalgia

723.4

Brachial neuritis or radiculitis, not otherwise specified

724.2

Lumbago

724.3

Sciatica

724.4

Thoracic or lumbosacral neuritis or radiculitis, unspecified

728.2

Muscular wasting and disuse atrophy, not elsewhere classified

728.85

Spasm of muscle

729.2

Neuralgia, neuritis, and radiculitis, unspecified

729.5

Pain in limb

736.05

Wrist drop (acquired)

736.79

Other acquired deformities of foot and ankle (foot drop)

780.79

Other malaise and fatigue (generalized weakness)

781.3

Lack of coordination

782.0

Disturbance of skin sensation

957.1, 957.8, 957.9

Injury to other and unspecified nerves

ICD-10 Diagnoses Codes That Support Medical Necessity (Effective 10/01/15):

E10.40 – E10.49

Type 1 diabetes mellitus with diabetic neuropathy, unspecified

E10.610

Type 1 diabetes mellitus with diabetic neuropathic arthropathy

E11.40 – E11.49

Type 2 diabetes mellitus with diabetic neuropathy, unspecified

E11.610

Type 2 diabetes mellitus with diabetic neuropathic arthropathy

E13.42

Other specified diabetes mellitus with diabetic polyneuropathy

G12.0

Infantile spinal muscular atrophy, type 1 (Werdnig-Hoffman)

G12.1

Other inherited spinal muscular atrophy

G12.20

Motor neuron disease, unspecified

G12.21

Amyotrophic lateral sclerosis

G12.22

Progressive bulbar palsy

G12.29

Other motor neuron disease

G12.8

Other spinal muscular atrophies and related syndromes

G12.9

Spinal muscular atrophy, unspecified

G54.0 – G54.9

Nerve root and plexus disorders

G55

Nerve root and plexus compressions in diseases classified elsewhere

G56.00 – G56.92

Mononeuropathies of upper limb

G57.00 – G57.92

Mononeuropathies of lower limb

G589

Mononeuropathy, unspecified

G60.0 – G60.8

Hereditary and idiopathic neuropathy

G61.0 – G61.9

Inflammatory polyneuropathy

G62.0 – G62.9

Other and unspecified polyneuropathies

G63

Polyneuropathy in diseases classified elsewhere

G64

Other disorders of peripheral nervous system

G70.00 – G70.01

Myasthenia gravis

G71.0

Muscular dystrophy

G71.11 – G71.19

Myotonic disorders

G71.2

Congenital myopathies

G71.3

Mitochondrial myopathy, not elsewhere classified

G71.8

Other primary disorders of muscles

G71.9

Primary disorder of muscle, unspecified

G72.0 – G72.9

Other and unspecified myopathies

G73.1 – G73.7

Disorders of myoneural junction and muscle in diseases classified elsewhere

G90.50

Complex regional pain syndrome I, unspecified

G90.511 – G90.519

Complex regional pain syndrome I, upper limb

G90.519

Complex regional pain syndrome I of unspecified upper limb

G90.521 – G90.529

Complex regional pain syndrome I, lower limb

G90.529

Complex regional pain syndrome I of unspecified lower limb

G90.59

Complex regional pain syndrome I of other specified site

G93.3

Postviral fatigue syndrome

M21.331 – M21.339

Wrist drop (acquired)

M21.371 – M21.379, M21,6x1 – M21.6x9

Other acquired deformities of foot and ankle (foot drop)

M21.961, M21.962, M21.969

Unspecified acquired deformity of lower leg

M50.10 – M50.13

Cervical disc disorder with radiculopathy

M51.14 – M51.17

Radiculopathy (thoracic, thoracolumbar, lumbar, or lumbosacral)

M54.10 – M54.18

Neuritis or radiculitis

M54.2

Cervicalgia

M54.30 – M54.32

Sciatica

M54.40 – M54.42, M54.5

Lumbago

M62.40, M62.411- M62.49

Muscle contractures

M62.50 – M62.59

Muscle wasting and atrophy, not elsewhere classified

M62.830 – M62.838

Spasm of muscle

M79.2

Neuralgia, neuritis and radiculitis, unspecified

M79.601 – M79.676

Pain in limb

M96.1

Postlaminectomy syndrome, not elsewhere classified

R20.0 – R20.9

Disturbance of skin sensation

R27.0 – R27.9

Lack of coordination

R53.0

Neoplastic (malignant) related fatigue

R53.1

Weakness

R53.81 – R53.83

Other malaise and fatigue (generalized weakness)

S14.2xxA – S14.9xxA

S14.2xxD – S14.9xxD

S14.2xxS – S14.9xxS

Injury to other and unspecified nerves

S34.6xxA – S34.6xxS

S34.8xxA – S34.8xxS

S34.9xxA – S34.9xxS

Injury of nerves of abdomen, lower back, and pelvis level

S84.801A – S84.801S

S84.802A – S84.802S

S84.809A –S84.809S

Injury of other nerves at lower leg level

S94.8x1A – S94.8x1S

S94.8x2A – S94.8x2S

S94.8x9A – S94.8x9S

Injury to other nerves of ankle and foot level

REIMBURSEMENT INFORMATION:

Reimbursement for electrodiagnostic testing requires that the professional component be reported by the supervising physician rather than by an out-sourced entity.

Reimbursement for nerve conduction study codes 95907, 95908, 95909, 95910, 95911, 95912, OR 95913 is limited to one nerve conduction studies code per day and is limited to a combined total of three (3) in 6 months; services beyond these limitations are subject to medical review of medical necessity.

Reimbursement for needle electromyography is limited to the following:

NOTE: Services in excess of these limitations are subject to medical review for medical necessity and would include conditions such as, but not limited to, patients with complex neuromuscular disorders or patients whose conditions are changing rapidly. Documentation should include physician progress notes and physician procedure notes documenting the patient’s history of sensory and/or motor nerve dysfunction and should include a printed recording of the nerve conduction study (NCS) test results. NCS reports should document the nerves evaluated, the distance between the stimulation and recording sites, conduction velocity, latency values, and amplitude. The temperature of the studied limbs may be included.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Attending physician progress notes

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician procedure note

11505-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Neuromuscular Electrophysiology Studies ( i.e., nerve conduction study [NCS] test results)

27897-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following Local Coverage Determination (LCD) was reviewed on the last guideline revised date: Electromyography and Nerve Conduction Studies (L21964) located at fcso.com.

DEFINITIONS:

Antidromic: conducting impulses in a direction opposite to the normal.

Gastrocnemius: the largest and most superficial muscle of the calf of the leg that arises by two heads from the condyles of the femur and has its tendon of insertion incorporated as part of the Achilles tendon; also called gastrocnemius muscle.

Mononeuropathy multiplex: signifies focal involvement of two or more nerves, usually as a result of generalized disorder, such as diabetes mellitus or vasculitis.

Mononeuropathy: a disorder of a single nerve and is often due to local causes such as trauma or entrapment as in carpal tunnel syndrome. Patients with mononeuropathies exhibit motor and/or sensory symptoms and signs due to injury of a particular nerve.

Myopathies: a diverse group of disorders characterized by primary dysfunction of skeletal muscles and include polymyositis, muscular dystrophy, and congenital, toxic and metabolic myopathies.

Neuritis: inflammatory disorders of nerves resulting from infection or autoimmunity.

Neuronopathies: occur in diverse forms, at varying ages, and with varied clinical presentations; can be both acquired and inherited. The common feature is pathophysiology of either the motor neurons in the anterior horn of the spinal cord (motor neuronopathies) or, less commonly, of the dorsal root ganglia (sensory neuronopathies).

Orthodromic: conducting impulses in the normal direction; said of nerve fibers.

Peripheral neuropathy and polyneuropathy: syndromes resulting from diffuse lesions of peripheral nerves, usually manifest by weakness, sensory loss, and autonomic dysfunction.

Plexopathies-plexi: located between the roots and peripheral nerves, and their disorders often pose a clinical challenge. The manifestations of a plexopathy may be distant from the actual site of nerve injury.

Polyneuropathies: diseases, which affect peripheral nerve axons, their myelin sheaths, or both; manifested by sensory, motor and autonomic signs and symptoms.

Radiculitis: inflammation of spinal nerve roots, accompanied by pain and hyperesthesia.

Radiculopathy: any diseased condition of roots of spinal nerves.

Reflex sympathetic dystrophy: is an excessive or abnormal response of the sympathetic nervous system to injury of the shoulder and arm, rarely the leg; burning or aching pain following trauma to an extremity of a severity greater than that expected from the initiating injury; pain, usually burning or aching, in an injured extremity is the single most common findings. Manifestations of vasomotor instability are generally present and include temperature, color, and texture alterations of the skin of the involved extremity.

Soleus: a broad flat muscle of the calf of the leg that lies deep to the gastrocnemius, arises from the back and upper part of the tibia and fibula and from a tendinous arch between them, inserts by a tendon that unites with that of the gastrocnemius to form the Achilles tendon; acts to flex the foot.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM). Proper performance and interpretation of electrodiagnostic studies. Muscle Nerve 2006; 33(3):436-9.
  2. American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM) Model Policy for Needle Electromyography and Nerve Conduction Studies. Accessed 06/07/11.
  3. Blue Cross and Blue Shield Association Medical Policy Reference Manual, 2.01.77 Automated Point-of-Care Nerve Conduction Tests, (06/06/10).
  4. ECRI Health Technology Assessment Information Services. Custom Hotline Response. Point of Care Nerve Conduction Tests. Updated 05/02/07.
  5. Florida Medicare Part B Local Coverage Determination. L21964 Electromyography and Nerve Conduction Studies. 01/01/10.
  6. Hayes, Inc. Health Technology Brief. Nc-stat® System (NeuroMetrix Inc.) for Noninvasive Nerve Conduction Testing of Upper Extremity Neuropathy. Lansdale, PA: Hayes, Inc.; February 2007. Update performed 02/28/08.
  7. Jablecki CK, Andary MT, Floeter MK, Miller RG, Quartly CA, Vennix MJ, Wilson JR; American Association of Electrodiagnostic Medicine; American Academy of Neurology; American Academy of Physical Medicine and Rehabilitation. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002 Jun 11; 58(11): 1589-92.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 06/23/11.

GUIDELINE UPDATE INFORMATION:

11/15/01

Medical Coverage Guideline Reformatted and revised.

12/15/02

Added coverage information added for current perception threshold testing (G0255).

10/15/03

Annual Review. Developed separate MCG 01-95805-18 for Current Perception Threshold Testing.

03/15/04

Review and revision to guideline consisting of adding additional ICD-9 codes.

09/15/07

Review and revision of guideline consisting of updated references and reformatted guideline.

09/15/08

Review and revision of guideline consisting of updated references.

07/15/09

Revision of Position Statement to add coverage criteria; updated ICD-9 diagnosis code table to include fifth digit specificity as applicable; add reimbursement statement regarding billing of professional components; updated references.

01/01/10

Annual HCPCS coding update: added 95905.

10/15/10

Revision; related ICD-10 codes added.

04/01/11

2nd Quarter HCPCS coding update: deleted S3905.

07/15/11

Scheduled review; position statement unchanged; related ICD-10 codes added; formatting changes, and references updated.

01/01/12

Annual HCPCS coding update: added 95885, 95886, and 95887.

03/15/12

Revision; added Medicare Program Exception regarding 95905.

06/15/12

Added coding information relevant to 95920.

01/01/13

Annual CPT/HCPCS coding update: added 95907-95913; deleted 95900, 95903, 95904, 95934, and 95936; revised coding notation to replace 95920 with 95940 and 95941; added G0453; updated reimbursement section.

05/11/14

Revision: Program Exceptions section updated.

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is copyright 2013, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2013 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association.The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

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Date Printed: September 16, 2014: 07:27 PM