Subject:
Nutritional Support (Infant Formulas, Enteral Nutrition and Total Parenteral Nutrition)
Description:
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IMPORTANT NOTE:
The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.
Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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An infant formula is defined by the United States Federal Food, Drug and Cosmetic Act (FFDCA) as "a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk". Food and Drug Administration (FDA) regulations define infants as persons not more than 12 months old. Commercial infant formulas are regulated by the FDA. According to information from the Mayo Clinic, infant formula can be a practical and safe alternative to breast milk. Breast milk is the best source of infant nutrition. However, providing breast milk for the entire first year of life may not be feasible for all mothers. Infant formulas offer another option.
There are three (3) main types of infant formulas:
- Cow's milk formulas - most infant formula is made with cow's milk that has been altered to resemble human breast milk. This gives the formula the right balance of nutrients and makes it easier to digest. Although most infants do well on cow's milk formula, some need other types of infant formula including, but not limited to, infants who are allergic to the proteins in cow's milk.
- Soy-based formulas - this may be an option for infants who are intolerant or allergic to cow's milk formula or to lactose, a sugar naturally found in cow's milk. Some infants who are allergic to cow's milk may also be allergic to soy milk.
- Protein hydrolysate formulas - these hypoallergenic formulas are meant for infants who have allergies to cow's and soy-based milk. Protein hydrolysate formulas are easier to digest and less likely to cause allergic reactions than other types of formula.
In addition, specialized infant formulas are available for premature infants and those who have specific medical conditions.
Enteral nutrition (EN) is used for patients with a functioning intestinal tract, but with disorders of the pharynx, esophagus, or stomach that prevent nutrients from reaching the absorbing surfaces in the small intestine. The patient is at risk of severe malnutrition. EN involves administering non-sterile liquids directly into the gastrointestinal tract through nasogastric, gastrostomy, or jejunostomy tubes. An infusion pump may be used to assist the flow of liquids. Feedings may be either intermittent or continuous (infused 24 hours a day).
Total parenteral nutrition (TPN), also known as parenteral hyperalimentation, is used for patients with medical conditions that impair gastrointestinal absorption to a degree incompatible with life. It is also used for variable periods of time to bolster the nutritional status of severely malnourished patients with medical or surgical conditions. TPN involves percutaneous transvenous implantation of a central venous catheter into the vena cava or right atrium. A nutritionally adequate hypertonic solution consisting of glucose (sugar), amino acids (protein), electrolytes (sodium, potassium), vitamins and minerals, and sometimes fats is administered daily. An infusion pump is generally used to assure a steady flow of the solution either on a continuous (24-hour) or intermittent schedule. If intermittent, a heparin lock device and diluted heparin are used to prevent clotting inside the catheter.
Policy:
[INFORMATIONAL NOTE: Also refer to a separate policy on Medical Nutritional Therapy (Inherited Metabolic Disease Mandate), Policy #018 in the Treatment Section.
For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. Infant Formulas and Mandated Benefits:
A. Administered Orally:
Please note that currently, all infant formulas and supplements do not require prescription by a physician; thus, they are not eligible for reimbursement. This is based on contract exclusion language and is not subject to medical necessity review. However, coverage is required under the following mandates:
- Inherited Metabolic Disease Mandate - "Medical foods" and "low protein modified food products" are covered in accordance with the New Jersey State Mandate for coverage of treatment of inherited metabolic disease. (Please refer to a separate policy on Medical Nutritional Therapy for Inherited Metabolic Disease - Policy #018 in the Treatment Section of this database.)
- Infant Formula Mandate - "Specialized non-standard infant formulas" are covered in accordance with the New Jersey State Mandate for coverage of certain infant formulas. The mandate requires that benefits be provided "for expenses incurred in the purchase of specialized non-standard infant formulas, when the covered infant’s physician has diagnosed the infant as having multiple food protein intolerance and has determined such formula to be medically necessary, and when the covered infant has not been responsive to trials of standard non-cow milk-based formulas, including soybean and goat milk." Note that the mandate requires trial(s) of any standard non-cow milk-based formula or any reasonable combination. [An infant is defined as up to 12 months of age. This definition is consistent with information from the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC), and the United Nations Population Information Network (POPIN).]
Informational Note: as of 10/9/2019 there are no facilities in the State of New Jersey that are licensed and certified to supply human breast milk. Therefore, this is not in effect at this time.
- Human Breast Milk - DONATED HUMAN BREAST MILK
For fully insured, SHBP and ASO groups which have opted in, An Act concerning coverage for donated human breast milk went in to effect January 1, 2019 which provides for insurance coverage for the following:
Expenses incurred in the provision of pasteurized donated human breast milk (including human milk fortifiers) are covered in accordance with the state mandates for individuals enrolled in a New Jersey product subject to New Jersey's insurance law.
Coverage of pasteurized donated human breast milk, which may include human milk fortifiers, is based on meeting criteria which include the following:
I. The covered person is an infant under the age of six months
II. The milk is obtained from a human milk bank that meets quality guidelines established by the Department of Health
III. The licensed medical practitioner who is prescribing the milk must meet one of the following requirements:
a. The licensed medical practitioner has issued an order for an infant who is medically or physically unable to receive maternal breast milk or participate in breast feeding or whose mother is medically or physically unable to produce maternal breast milk in sufficient quantities or participate in breast feeding despite optimal lactation support; or
b. The licensed medical practitioner has issued an order for an infant who meets any of the following conditions:
1) a body weight below healthy levels determined by the licensed medical practitioner
2) a congenital or acquired condition that places the infant at a high risk for development of necrotizing enterocolitis
3) a congenital or acquired condition that may benefit from the use of donor breast milk as determined by the Department of Health
Coverage for donated human breast milk is subject to utilization review, including periodic review, of the continued medical necessity.
NOTE: If there is no supply of human breast milk that meets the above requirements, the insurer shall not be required to provide coverage of expenses pursuant to this section.
According to UpToDate's review article on the management of milk allergy, most patients with cow's milk allergy (CMA) do not tolerate milk from sheep and goats. Significant amino acid sequence homology and resulting high rate of clinical cross-reactivity between milk from ruminants (e.g., approximately 90 percent of children with IgE-mediated CMA react to goat's milk) makes milk from sheep and goats inappropriate feeding alternatives for most cow's milk-allergic individuals.
A recommendation from the 2010 Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) summary report from the 2nd Milan Meeting on Adverse Reactions to Bovine Proteins suggests extensively hydrolyzed milk formula rather than soy formula in children with IgE-mediated cow's milk allergy (conditional recommendation/very low-quality evidence) and that soy should not be used in the first 6 months of life because of nutritional risk.
When a specialized non-standard infant formula is being given for continued therapy beyond the infancy period (i.e. more than 12 months of age), its eligibility may be extended when there is clear documentation (i.e., copies of original medical records submitted either hard copy or electronically by the treating physician) that a reasonable treatment plan has been implemented to introduce new food sources to wean the child off the formula. In addition, the progress notes must document the type of food(s) being introduced, the quantity, the frequency, and the child’s reaction (when appropriate).
B. Administered via an Enteral Feeding Tube:
Infant formulas are eligible for reimbursement when the medical necessity criteria for enteral nutrition are met. (Refer to policy statement III below.)
II. Formulas and Supplements for Other than Infants:
A. Administered Orally:
Formulas and supplements administered orally for other than infants may be considered medically necessary for certain medical conditions (e.g., elemental formula for eosinophilic esophagitis). However, since these formulas and supplements do not require prescription by a physician, they are not eligible for reimbursement. This is based on contract exclusion language and is not subject to medical necessity review.
B. Administered via an Enteral Feeding Tube:
Formulas and supplements administered via an enteral feeding tube are eligible for reimbursement when the medical necessity criteria for enteral nutrition are met. (Refer to policy statement III below)
III. Enteral Nutrition (EN):
Enteral nutrition is medically necessary when both of the following lettered criteria are met:
A. An anatomical inability to swallow due to, for example, head and neck cancer or an obstructing tumor or stricture of the esophagus (e.g., due to eosinophilic esophagitis) or stomach;
A central nervous system disease leading to sufficient interference with the neuromuscular coordination of chewing and swallowing creating a risk of aspiration;
B. It is the sole source of nutrition. [This means that the member’s total daily caloric requirement to maintain body weight (typically around 2000-2200 calories depending on the individual’s size and weight) is exclusively provided by the enteral formula given through the feeding tube.]
(Refer to policy statement I.B. above for eligibility of infant formulas administered through an enteral feeding tube.
For eligibility of items and services related to a medically necessary enteral nutrition, refer to policy statement VI below.)
IV. Total Parenteral Nutrition (TPN):
Total parenteral nutrition is medically necessary when both of the following lettered criteria are met:
A. The member has any of the following diseases or conditions that result in impaired intestinal absorption, including but not limited to:
- Crohn’s disease;
- obstruction secondary to stricture or neoplasm of the esophagus or stomach;
- loss of the swallowing mechanism due to a central nervous system disorder, where the risk of aspiration is great;
- short bowel syndrome secondary to massive small bowel resection;
- malabsorption due to enterocolic, enterovesical, or enterocutaneous fistulas (TPN being temporary until the fistula is repaired);
- motility disorder (pseudo-obstruction);
- newborn infants with catastrophic gastrointestinal anomalies such as tracheoesophageal fistula, gastroschisis, omphalocele, or massive intestinal atresia;
- infants and young children who fail to thrive due to systemic disease or secondarily to intestinal insufficiency associated with short bowel syndrome, malabsorption, or chronic idiopathic diarrhea;
- patients with prolonged paralytic ileus following major surgery or multiple injuries;
B. The member is in a stage of wasting with any of the following:
- weight is significantly less than normal body weight for a patient’s height and age in comparison with pre-illness weight;
- serum albumin is less than 2.5 gm;
- blood urea nitrogen (BUN) is below 10 mg (but this is not a good marker in patients receiving dialysis due to protein catabolism);
- phosphorus level is less than 2.5 mg (normal phosphorus is 3–4.5 mg);
- the patient can receive no more than 30% of his/her caloric needs orally or the patient cannot benefit from tube feedings as a result of a malabsorptive disorder.
(NOTE: BUN and phosphorous levels may not be good markers of wasting in members with chronic kidney disease.)
Long-term PN is medically necessary for members with prolonged gastrointestinal tract failure that prevents the absorption of adequate nutrients to sustain life.
(For eligibility of items and services related to a medically necessary total parenteral nutrition, refer to policy statement VI below.)
V. Supplemental EN:
In general, a daily caloric intake of 2000-2200 calories is sufficient to maintain body weight. If 750 calories or less are being administered by EN, they are considered supplemental and are not medically necessary.
VI. Eligible items and services associated with a medically necessary EN* (please refer to exception noted below) or TPN include, but are not limited to, the following:
- cost of nutrients that require a physician's prescription (enteral formulas and parenteral nutritional solutions);
(Refer to policy statement I.B. above for eligibility of infant formulas administered through an enteral feeding tube.)
- cost of rental or purchase of an infusion pump and heparin lock;
- supplies and equipment necessary for the proper functioning and effective use of a EN or TPN system (e.g., catheters, dressings, IV stand, needles, filters, extension tubing, and concentrated nutrients);
- home visits by a physician;
- home visits by a registered nurse (R.N.) or licensed practical nurse (L.P.N.) under the order and supervision of a physician;
- placement of gastrostomy or jejunostomy feeding tubes and central venous catheters.
* Exception: An enteral pump (B9000-B9002) and associated supplies are medically necessary for administration of medication and/or an enteral product (when criteria are not met) if the member is at risk of or experiences:
- complications associated with syringe or gravity method of administration, and
- documentation in the member's medical record submitted either hard copy or electronically that supports its use (e.g., gravity feeding is not satisfactory due to reflux and/or aspiration, severe diarrhea, dumping syndrome, administration rate less than 100 ml/hr, blood glucose fluctuations, circulatory overload, gastrostomy/jejunostomy tube used for feeding).
VII. Ineligible items and services include, but are not limited to, the following:
- blenderized baby food and regular shelf food used with an enteral system;
- substances to increase protein or caloric intake in addition to the member's daily diet;
- member with a stable nutritional status in whom only short-term parenteral nutrition might be required (i.e., for less than 2 weeks);
- routine pre- and/or post-operative care;
- over-the-counter enteral nutritional substances.
- digestive enzyme cartridges (e.g., RelizorbTM, Alcresta Pharmaceuticals) for use with enteral tube feedings are considered investigational due to insufficient evidence of safety and efficacy in published peer-reviewed medical literature.
Medicare Coverage:
Per NCD 180.2, Coverage of nutritional therapy under Medicare Part B requires that the patient must have a permanently inoperative internal body organ or function thereof. Therefore, enteral and parenteral nutritional therapy are normally not covered under Part B in situations involving temporary impairments.
Per LCD L33783, Enteral formulas consisting of semi-synthetic intact protein/protein isolates (B4150 or B4152) are appropriate for the majority of beneficiaries requiring enteral nutrition. The medical necessity for special enteral formulas (B4149, B4153-B4155, B4157, B4161, and B4162) must be justified in each beneficiary. If a special enteral nutrition formula is provided and if the medical record does not document why that item is medically necessary, it will be denied as not reasonable and necessary.
There are a number of NCDs and LCDs applicable to Nutritional Support (Infant Formulas, Enteral Nutrition and Total Parenteral Nutrition). For additional information and eligibility, refer to the below:
National Coverage Determination (NCD) for Enteral and Parenteral Nutritional Therapy (180.2).
National Coverage Determination (NCD) for Medical Nutrition Therapy (180.1).
NCDs available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx.
Local Coverage Determination (LCD): Enteral Nutrition (L33783).
Local Coverage Article: Enteral Nutrition - Policy Article (A52493)
Local Coverage Determination (LCD): Parenteral Nutrition (L33798)
LCDs and Article available to be accessed at Noridian Healthcare Services, LLC, (DME MAC), Local Coverage Determinations (LCDs) search page: https://www.cms.gov/medicare-coverage-database/indexes/lcd-list.aspx?Cntrctr=389&ContrVer=1&CntrctrSelected=389*1&s=38&DocType=All&bc=AggAAAAAAAAAAA%3d%3d&#ResultsAnchor.
Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for this service. Therefore, Medicare Advantage Products will follow the
Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
FIDE SNP:
For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.
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Horizon BCBSNJ Medical Policy Development Process:
This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.
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Index:
Nutritional Support (Infant Formulas, Enteral Nutrition and Total Parenteral Nutrition)
Nutritional Support
Enteral Nutrition
Hyperalimentation
Infant Formula
Parenteral Nutrition, Total
Total Parenteral Nutrition
TPN
Relizorb
Digestive Enzyme Cartridges
References:
1. New Jersey State Mandate (P.L. 1997, c. 338) approved January 12, 1998, which mandates health benefits coverage for therapeutic treatment of inherited metabolic disease, including coverage for certain foods and food products.
2. New Jersey State Mandate (P.L. 2001, c. 361) approved January 6, 2002, which requires benefits for expenses incurred in the purchase of certain infant formulas.
3. National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention. (www.cdc.gov/nchs/) (accessed 04/11/2002)
4. United Nations Population Information Network (POPIN). (www.un.org/popin/) (accessed 05/14/2002)
5. Centers for Medicare & Medicaid (CMS). National Coverage Determinations (NCDs): NCD for Enteral and Parenteral Nutritional Therapy. Manual Section Number: 180.2; Effective Date: 7/11/1984. [Available at http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=180.2&ncd_version=1&basket=ncd%3A180%2E2%3A1%3AEnteral+and+Parenteral+Nutritional+Therapy (last accessed 9/19/2006).]
6. UpToDate. Milk allergy: Management. Last updated: February 28, 2012.
7. Fiocchi A, Schunemann HJ, Brozek J et al. Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA): a summary report. J Allergy Clin Immunol. 2010 Dec;126(6):1119-28.e12.
8. UpToDate. Treatment of eosinophilic esophagitis. Last updated: Aug. 6, 2012. (accessed 10/02/12).
9. Liacouras CA, Furuta GT, Hirano I et al. Eosinophilic esophagitis: updated consensus recommendation for children and adults. J Allergy Clin Immunol. 2011 Jul;128(1):3-20.
10. NHIC, Corp. Local Coverage Determination (LCD): Enteral Nutrition (L33783). Available at https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33783&ContrId=137&ver=3&ContrVer=1&CntrctrSelected=137*1&Cntrctr=137&name=NHIC%2c+Corp.+(16003%2c+DME+MAC)&DocType=Active%7cFuture&s=All&bc=AggAAAIAAAAAAA%3d%3d&
11. ESPEN Guidelines on Parenteral Nutrition: home parenteral nutrition (HPN) in adult patients. Clin Nutr. 2009 Aug;28(4):467-79.
12. Borowitz DS, Grant RJ, Durie PR. Use of pancreatic enzyme supplements for patients with cystic fibrosis in the context of fibrosing colonopathy. J Pediatr. 1995;127:681-84.
13. Freedman S, Orenstein D, Black P, et al. Increased Fat Absorption from Enteral Formula through an In-Line Digestive Cartridge in Patients with Cystic Fibrosis. Journal of Pediatric Gastroenterology and Nutrition. 2017 Jul;65 (1):97-101.
14. ClinicalTrials.gov. Safety, Tolerability and Fat Absorption Using Enteral Feeding In-Line Enzyme Cartridge (Relizorb). Available at: https://clinicaltrials.gov/ct2/show/record/NCT02598128
15. Staun M, Pironi L, Bozzetti F, et al. ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients. Clinical Nutrition 28 (2009):467-479.
16. Cano NJM, Aparicio M, Brunori G, et al. ESPEN Guidelines on Parenteral Nutrition: Adult Renal Failure. Clinical Nutrition 28 (2009):401-414.
17. Staun M, Pironi L, Bozzetti F, et al. ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients. Clinical Nutrition 28 (2009):467-479.
18. Anker SD, Laviano A, Filippatos G, et al. ESPEN Guidelines on Parenteral Nutrition: On Cardiology and Pneumology. Clinical Nutrition 28 (2009):455-460.
19. Staun M, Pironi L, Bozzetti F, et al. ESPEN Guidelines on Parenteral Nutrition: Home Parenteral Nutrition (HPN) in adult patients. Clinical Nutrition 28 (2009):467-479.
20. Pittiruti M, Hamilton H, Biffi R, et al. ESPEN Guidelines on Parenteral Nutrition: Central Venous Catheters (access, care diagnosis and therapy of complications). Clinical Nutrition 28 (2009):365-377.
21. Van Gossum A, Cabre E, Hebuterne X, et al. ESPEN Guidelines on Parenteral Nutrition: Gastroenterology. Clinical Nutrition 28 (2009):415-427.
22. Sobotka L, Schneider SM, Berner YN, et al. ESPEN Guidelines on Parenteral Nutrition: Geriatrics. Clinical Nutrition 28 (2009):461-466.
23. Plauth M, Cabre E, Campillo B, et al. ESPEN Guidelines on Parenteral Nutrition: Hepatology. Clinical Nutrition 28 (2009): 436-444.
24. Singer P, Berger MM, Van den Berghe G, et al. ESPEN Guidelines on Parenteral Nutrition: Intensive Care. Clinical Nutrition 28 (2009): 387-400.
25. Bozzetti F, Arends J, Lundholm K, et al. ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology. Clinical Nutrition 28 (2009):445-454.
26. Gianotti L, Meier R, Lobo DN, et al. ESPEN Guidelines on Parenteral Nutrition: Pancreas. Clinical Nutrition 28 (2009):428-435.
27. Bozzetti F, Forbes A. ESPEN clinical practice guidelines on Parenteral Nutrition: Present status and perspectives for future research. Clinical Nutrition 28 (2009):359-364.
28. Braga M, Ljungqvist O, Soeters P, et al. ESPEN Guidelines on Parenteral Nutrition: Surgery. Clinical Nutrition 28 (2009):378-386.
29. NJ Mandate Publication S2976; P.L. 2017, c.309
Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)
CPT*
HCPCS
B4102
B4103
B4104
B4105
B4149
B4150
B4152
B4153
B4154
B4155
B4157
B4158
B4159
B4160
B4161
B4162
B4164
B4168
B4172
B4176
B4178
B4180
B4185
B4189
B4193
B4197
B4199
B4216
B4220
B4222
B4224
B5000
B5100
B5200
B9002
B9004
B9006
B9998
B9999
S9340
S9341
S9342
S9343
S9364
S9365
S9366
S9367
S9368
* CPT copyright 2019 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.
The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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