Subject:
Insulin Infusion Pumps
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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Insulin replacement therapy can be either conventional (usually injections twice daily) or intensive (injections three or more times daily or alternatively by continuous insulin infusion).
Within the past few years, "intensive therapy" for diabetes management has gained favor as it seems to offer the greatest hope of preventing diabetic complications. The rationale for intensive therapy comes from the results of the 10-year-long Diabetes Control and Complications Trial (DCCT) published in 1993, which showed that the progression of secondary complications of diabetes (i.e., development of diabetic retinopathy, nephropathy, and neuropathy) was slower in patients given intensive insulin therapy than in those given conventional therapy.
Continuous insulin infusion may be delivered via an external infusion pump or an implantable infusion pump:
I. External insulin infusion pump:
External insulin infusion pumps may or may not have a plastic catheter (tubing) that connects the needle to the insulin reservoir.
A. External insulin infusion pumps with a plastic catheter (tubing):
This is the more common type of external infusion pumps. It is comprised of an insulin reservoir, a battery operated infusion rate selector, and a plastic catheter (tubing) which connects the needle to the insulin reservoir. The external insulin pump is worn externally and delivers insulin through the needle placed subcutaneously into the abdominal wall. It is usually the size of a portable cassette player and can be worn on a belt around the patient’s waist or from a shoulder harness. It is a battery-driven device and drug reservoir refilling is non-invasive. Examples of this type of insulin pump are Animas' IR 1250, Smith/Deltec's Cozmo 1800, Roche/Disetronic's Accu-Chek Spirit and Medtronic Minimed's Paradigm 522/722 insulin pumps.
Medtronic MiniMed's Paradigm 522/722 Insulin Pump has an integrated continuous glucose monitoring receiver/monitor which, when activated, can be used with the optional Guardian REAL-Time CGM Starter Kit (MiniLink REAL-Time transmitter and disposable glucose sensors) for real-time continuous glucose monitoring. However, the Paradigm 522/722 Insulin Pump can function independently of the REAL-Time CGM Starter Kit. For more details on the Paradigm REAL-Time CGM Starter Kit, please refer to a separate policy on 'Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid' (Policy # 009) in the DME Section of this database.]
B. External insulin infusion pumps without a plastic catheter (tubing):
The OmniPod Insulin Management System (by Insulet Corp.) received FDA approval for marketing on January 3, 2005. The OmniPod System has two parts: a small self-adhesive insulin pod (i.e., the OmniPod) that integrates the tubing, infusion set, automatic cannula inserter, insulin reservoir and power supply, and a remote controller (the Personal Diabetes Manager [PDM]), a wireless handheld device that programs the OmniPod with customized insulin delivery instructions and incorporates a traditional blood glucose meter using FreeStyle test strips. The pod and the remote controller interact wirelessly using bi-directional radiofrequency (RF). The pod is worn for up to 3 days, and then removed/discarded and replaced with a new pod filled with insulin.
The V-Go Insulin Delivery Device ( by Valeritas, Inc.) received FDA approval for marketing on December 1, 2010 and February 23, 2011 for use with short acting insulin Humalog and NovoLog respectively. It is a mechanical (no electronics), self-contained, sterile, patient fillable, single-use (24 hours) disposable insulin infusion device with an integrated stainless steel subcutaneous needle. It comes in 3 models: V-Go 20, V-Go 30, and V-Go 40. The device has two delivery systems, one for preset basal rate infusion and another for on-demand bolus delivery. The device is worn for 24 hours, and then removed/discarded and replaced with a new device filled with short acting insulin by the patient.
II. Implantable insulin infusion pump:
The implantable infusion pump (IIP) is surgically placed in a subcutaneous pocket under the infraclavicular fossa or in the abdominal wall, and a catheter is threaded into the desired position. The drug reservoir may be refilled as needed by an external needle injection through a self-sealing septum in the IIP. The driving mechanisms for IIP may include peristalsis, fluorocarbon propellant, osmotic pressure, piezoelectric disk benders, or the combination of osmotic pressure with an oscillating piston.
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
I. The guiding principle of this policy is the New Jersey State Mandate (S-1759) on equipment and supplies for the treatment of diabetes.
The ensuing statements represent the interpretation of the law by Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) which must be strictly observed when handling pre-authorizations, claims, inquiries, and other matters pertaining to insulin infusion pumps:
- External continuous insulin infusion pumps with or without a plastic catheter (tubing) are automatically eligible for coverage under the law when recommended or prescribed by a physician or nurse practitioner/clinical nurse specialist for the treatment of diabetes. Medical appropriateness criteria may be applied regarding FDA age appropriateness for the pump and for type - if a basic type of pump meets a member's medical needs then a more complex type is not required to be approved. However, if a pump is deemed medically necessary by the provider, it may NOT be denied as not medically necessary provided the criteria for the pump is met.
- Implantable insulin infusion pumps are not covered under the law because none of these devices has received FDA approval for the management of diabetes. Thus, they are considered investigational.
- The law applies to contracts delivered, issued, executed or renewed in New Jersey. Services rendered outside New Jersey are covered by the law as long as the subscriber has a contract that is written or issued in New Jersey.
[Please note that self-insured accounts are exempt from the law. However, they have the option to adopt the requirements set forth in the law.]
II. The following medical necessity criteria must be applied only to those self-insured accounts which opted NOT to adopt the law:
A. The external insulin pump must be ordered by and follow-up care of the member must be managed by a physician who manages multiple members with continuous subcutaneous insulin infusion (CSII) and who works closely with a team including nurses, diabetic educators, and dietitians who are knowledgeable in the use of CSII.
B. The use of an external continuous subcutaneous insulin infusion pump and its accessories (e.g., infusion sets) is considered medically necessary in the management of insulin-requiring diabetic members when criterion 1 or 2 is met:
Criterion 1 (ALL must be met)
1. The member has completed a comprehensive diabetes education program, and
2. The member has been on a program of multiple daily injections of insulin (i.e., at least 3 injections per day), with frequent self-adjustments of insulin dose for at least 6 months prior to initiation of the insulin pump, and
3. The member has documented frequency of glucose self-testing an average of at least 4 times per day during the 2 months prior to initiation of the insulin pump or documented use of a therapeutic factory calibrated continuous glucose monitor (CGM) during the two months prior to initiation of an insulin pump, and
4. Has documentation of ANY of the following while on multiple daily injection regimen:
- glycosylated hemoglobin level (HbA1C) greater than 7 percent
- history of recurring hypoglycemia
- wide fluctuations in blood glucose before mealtime
- Dawn phenomenon with fasting blood sugars frequently exceeding 200 mg/dL
- history of severe glycemic excursions
OR
Criterion 2:
The insulin-requiring diabetic member has been on a pump prior to enrollment in Horizon Blue Cross Blue Shield of New Jersey and has a documented frequency of glucose self-testing an average of at least 4 times per day during the month prior to Horizon BCBSNJ enrollment or documented use of a therapeutic factory calibrated CGM during the month prior to Horizon BCBSNJ enrollment.
III. An external insulin pump with special features is considered medically necessary with documentation when criteria for a standard insulin pump are met with ANY of the following conditions (not an inclusive list):
- a special need such as hearing or visual impairment that requires enhanced feature for successful use of an insulin pump
- need for a larger reservoir
- member inability to achieve glycemic control adequate to prevent acute metabolic complications such as hyperglycemia, hypoglycemia, or ketoacidosis using a standard external insulin pump
- integrated bolus wizard function for children under age 18 years of age.
IV. External Insulin Pump Replacement
An external insulin pump may be replaced when:
- the pump is out of warranty and is malfunctioning and cannot be refurbished, and
- an expired warranty must be verified for replacement purposes.
Replacement of an insulin pump to upgrade or obtain the newest technology is not considered medically necessary.
V. External Insulin Pump for Preconception and Gestational Diabetes
Use of an external insulin pump for preconception and gestational diabetes is subject to medical review.
VI. Pediatric External Insulin Pump
Pediatric external insulin pump use is subject to medical review for those devices that are not FDA-approved for the age of the member.
VII. For the long-term use of a patient-use glucose monitoring device (sensor and MiniLink REAL-Time transmitter) which communicates wirelessly with a compatible external insulin pump (i.e., Paradigm 522/722 Insulin Pump), please refer to a separate medical policy on Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid (Policy #009 in the DME Section).
VIII. The use of implantable insulin infusion pump in the management of diabetes mellitus is considered investigational since no implantable pump has been approved by the FDA for this purpose.
IX. Personal computer or tablet software or accessories and smartphone apps for use in remote or self-monitoring are considered a convenience and thus, not medically necessary.
(NOTE: Refer to a separate policy on Definition of Medical Necessity (Policy #003) in the Introduction Section.)
X. For the use of an artificial pancreas system, including but not limited to closed-loop monitoring devices with low-glucose suspend (LGS) features, please refer to a separate medical policy on 'Artificial Pancreas Device System' (Policy #045) in the DME Section.
Medicare Coverage:
Medicare Advantage coverage differs from the Horizon BCBSNJ Medical Policy. For eligibility and coverage, please refer to the following National Coverage Determination, Local Coverage Determinations and Articles listed below.
National Coverage Determination (NCD) for Infusion Pumps 280.14. Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=223&ncdver=2&bc=AAAAgAAAAAAAAA%3d%3d&.
Local Coverage Determination (LCD): External Infusion Pumps L33794. Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33794&ver=77&Date=&DocID=L33794&bc=iAAAABAAAAAA&.
Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33794&ver=77&Date=&DocID=L33794&bc=iAAAABAAAAAA&
Local Coverage Article: External Infusion Pumps - Policy Article (A52507).
Local Coverage Article: Glucose Monitor - Policy Article (A52464). Available at: https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33794&ver=77&Date=&DocID=L33794&bc=iAAAABAAAAAA&
*For services for which there is no NCD or LCD, Medicare Advantage members will follow the Horizon BCBSNJ Medical Policy.
Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.
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:
Insulin Infusion Pumps
External Insulin Infusion Pump
Implantable Insulin Infusion Pump
Paradigm Wireless Diabetes Management System
Pumps, Insulin Infusion
Paradigm 522 Insulin Pump
Paradigm 722 Insulin Pump
Guardian REAL-Time CGMS
MiniLink REAL-Time Transmitter
OmniPod Insulin Management System
V-Go Insulin Delivery Device
References:
1. State of New Jersey Legislation S-1579 (an act concerning health insurance coverage for treatment of diabetes and supplementing various parts of the statutory law), approved on January 5, 1996.
2. Decision Memorandum. Continuous Subcutaneous Insulin Infusion Pump (CAG# -00041). Health Care Financing Administration. Baltimore, MD: August 6, 1999. <www.hcfa.gov/coverage/8b3-i2.htm> (accessed 05/22/01)
3. Blue Cross and Blue Shield Association. Medical Policy Reference Manual: External Infusion Pumps. 1:2003: Policy #1.01.08.
4. Blue Cross Blue Shield Association. Medical Policy Reference Manual: Implantable Infusion Pump. 04/15/02: Policy #7.01.41.
5. Health Technology Assessment Report No. 9: Reassessment of External insulin Infusion Pumps. Agency for Healthcare Policy and Research. Rockville, MD: July 1991. <//hstat.nlm.nih.gov/tempfiles/is/tempBrPg54639.html?t=991399466> (accessed 06/01/01)
6. The Diabetes Control and Complications Trial (DCCT) Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The New England Journal of Medicine. 1993 September 30;329(14):977-86.
7. Position Statement: Continuous Subcutaneous Insulin Infusion. American Diabetes Association: Clinical Practice Recommendations 2001. Vol. 24 Supplement 1. <www.diabetes.org/clinicalrecommendations/Supplement101/S98.htm> (accessed 05/31/01)
8. Committee Report: Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. American Diabetes Association: Clinical Practice Recommendations 2001. Vol. 24 Supplement 1. <www.diabetes.org/clinicalrecommendations/Supplement101/S5.htm> (accessed 05/31/01)
9. ECRI. Executive Briefings: Continuous subcutaneous insulin infusion pump therapy for diabetes. November 1994.
10. ECRI. Target Report #311: Implantable insulin infusion pumps for diabetes. August, 2001.
11. Medicare News: Medicare will cover insulin pumps for beneficiaries. HCFA. September 4, 1999.<www.hcfa.gov/news/pr1999/pr990924.htm> (accessed 06/01/01).
12. Centers for Medicare and Medicaid Services (CMS). Coverage Issues Manual - Durable Medical Equipment # 60-14: Infusion Pumps. http://www.cms.hhs.gov/manuals/06_cim/ci60.asp (last accessed 06/15/05).
13. Sulli N, Shashaj B. Continuous subcutaneous insulin infusion in children and adolescents with diabetes mellitus: decreased HbA1c with low risk of hypoglycemia. J Pediatr Endorinol Metab. 2003 Mar;16(3)393-9.
14. Plotnick LP, Clark LM et al. Safety and effectiveness of insulin pump therapy in children and adolescents with type 1 diabetes. Diabetes Care. 2003 Apr;26(4):1142-6.
15. Scuffham P, Carr L. The cost-effectiveness of continuous subcutaneous insulin infusion compared with multiple daily injections for the management of diabetes. Diabet Med. 2003 Jul;20(7):586-93.
16. Weissberg-Benchell J, Antisdel-Lomaglio J, Seshadri R. Insulin Pump Therapy: A meta-analysis. Diabetes Care. 2003 Apr;26(4):1079-87.
17. Information on Wireless Diabetes Management System. Medtronic. [Available at: http://www.medtronic.com (accessed 06/03/04).]
18. ECRI’s Health Technology Forecast: Closed-loop glucose measurement and insulin pump therapy for diabetes measurement. February, 2005.
19. FDA approval of the OmniPod Insulin Management System. Available at: http://www.fda.gov/cdrh/pdf4/K042792.pdf
20. Information on the OmniPod Insulin Management System. Available at: http://www.myomnipod.com/products/ (accessed 09/10/07).
21. Newman SP, Hurel SJ, Cooke D et al. A randomized control trial of continuous glucose monitoring devices on HbA1c - the MITRE study.
Presented at the American Diabetes Association's 67th Scientific Sessions. Accessible at http://scientificsessions.diabetes.org/index.cfm?fuseaction=Locator.Disp
laySearchAbstract&CalledByID=1006. Abstract 0115-OR.
22. Hitt E. Continuous Blood Glucose Monitoring Shows No Effect on Long-Term Glucose Control. Medscape Medical News, July 9, 2007.
Accessible at http://www.medscape.com/viewarticle/559486
23. Deiss D, Hartmann R et al. Results of randomized controlled cross-over trial on the effect of continuous glucose monitoring (CGMS) on glycaemic control in children and adolescents with type 1 diabetes. Exp Clin Endocrinol Diabetes. 2006 Feb;114(2):63-7.
24. Deiss D, Bolinder J, Reveline JP et al. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care. 2006 Dec;29(12):2730-2. http://care.diabetesjournals.org/cgi/reprint/29/12/2730 (http://care.diabetesjournals.org/cgi/reprint/29/12/2730)
25. National Government Services, Inc. (formerly known as Empire Medicare Services). Continuous Glucose Monitoring. LCD ID3 L3121. Effective date: 05/16/07. (accessed 05/18/07).
26. Highmark Medicare Services. Continuous Glucose Monitoring. LCD # M-58C. Revision effective date: 01/01/2006 (last accessed 08/17/07).
27. ECRI. TARGET Report # 896: Real-time continuous glucose monitoring. Published: June 2007.
28. Rodbard HW, Blonde L, Braithwaite S et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus. AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Endocrine Practice. 2007 May/June;13(1):4-68. Available at: http://www.aace.com/pub/pdf/guidelines/DMGuidelines2007.pdf (accessed 08/13/07).
29. Standards of Medical Care in Diabetes - 2007. American Diabetes Association - Position Statement. Diabetes Care. 2007 January;30(S1):S4-S41).
30. Canadian Agency for Drugs and Technologies in Health (CADTH). Issues in Emerging Health Technologies: Subcutaneous Open-loop Insulin Delivery for Type 1 Diabetes: Paradigm Real Time System. Issue 105, October 2007. Available at: http://www.cadth.ca/media/pdf/E0045_Type-1-Diabetes-Paradigm-Real-Time-System_cetap_e.pdf
31. Pozzilli P, Di Mari U. Autoimmune diabetes not requiring insulin at diagnosis (latent autoimmune diabetes of the adult): definition, characterization, and potential prevention. Diabetes Care. 2001 aug;24(8):1460-7.
32. Standards of Medical Care in Diabetes - 2008. American Diabetes Association. Diabetes Care. January 2008 (Vol. 31 Supplement 1), S12-S54.
33. Centers for Medicare and Medicaid Services (CMS). Decision Memo for Insulin Pump: C-Peptide Levels as a Criterion for Use (CAG-00092N). May 11, 2001. Available at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=41
34. Centers for Medicare and Medicaid Services (CMS). Decision Memo for Insulin Pump: C-Peptide Levels as a Criterion for Use (CAG-00092R).(first reconsideration) December 17, 2004. Available at: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=109
35. American Association of Clinical Endocrinologists (AACE). Consensus Panel on Continuous Glucose Monitoring. Endocrine Practice 2010 September/October;16(5).
36. The Endocrine Society Clinical Practice Guideline: Continuous Glucose Monitoring. J Clin Endocrinol Metab 2011 October;96(10):2968-2979.
37. The American Diabetes Association (ADA). Position Statement: 2012 Standards of Medical Care in Diabetes. Diabetes Care 2012 January;35 Supplement 1.
38. McCulloch DK. Blood glucose self-monitoring in management of adults with diabetes mellitus. In: UpToDate, Hirsch IB, Mulder JE (Eds), UpToDate, Waltham, MA. (Accessed on May 9, 2017.)
39. FDA approval for the V-Go Insulin Delivery Device available at: http://www.accessdata.fda.gov/cdrh_docs/pdf10/K103825.pdf
40. McCulloch DK. Management of blood glucose in adults with type 1 diabetes mellitus. In: UpToDate, Hirsch IB, Mulder JE (Eds), UpToDate, Waltham, MA. (Accessed on May 9, 2017.)
41. Levitsky LL, Misra M. Management of type 1 diabetes mellitus in children and adolescents. In: UpToDate, Wolfsdorf JI, Hoppin AG (Eds), UpToDate, Waltham, MA. (accessed on May 9, 2017.)
42. McCulloch DK. Insulin therapy in type 2 diabetes mellitus. In: UpToDate, Nathan DM, Mulder JE (Eds), UpToDate, Waltham, MA. (Accessed on May 9, 2017.)
43. Levitsky LL, Misra M. Management of type 1 diabetes mellitus in children and adolescents. In: UpToDate, Wolfsdorf JI, Hoppin AG (Eds), UpToDate, Waltham, MA. (accessed on May 1, 2018.)
44. Laffel L, Svoren B. Management of type 2 diabetes mellitus in children and adolescents. In: UpToDate, Wolfsdorf JI, Hoppin AG (Eds), UpToDate, Waltham, MA. (accessed on May 1, 2018.)
45. McCulloch DK. Management of blood glucose in adults with type 1 diabetes mellitus. In: UpToDate, Hirsch IB, Mulder JE (Eds), UpToDate, Waltham, MA. (Accessed on May 1, 2018.)
46. McCulloch DK. Insulin therapy in type 2 diabetes mellitus. In: UpToDate, Nathan DM, Mulder JE (Eds), UpToDate, Waltham, MA. (Accessed on May 1, 2018.)
47. Levitsky LL, Misra M. Management of type 1 diabetes mellitus in children and adolescents. In: UpToDate, Wolfsdorf JI, Hoppin AG (Eds), UpToDate, Waltham, MA. (accessed on July 23, 2020.)
48. Laffel L, Svoren B. Management of type 2 diabetes mellitus in children and adolescents. In: UpToDate, Wolfsdorf JI, Hoppin AG (Eds), UpToDate, Waltham, MA. (accessed on July 23, 2020.)
49. Weinstock RS. Management of blood glucose in adults with type 1 diabetes mellitus. In: UpToDate, Hirsch IB, Mulder JE (Eds), UpToDate, Waltham, MA. (accessed on July 23, 2020.)
50. Wexler DJ. Insulin therapy in type 2 diabetes mellitus. In: UpToDate, Nathan DM, Mulder JE (Eds), UpToDate, Waltham, MA. (accessed on July 23, 2020.)
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
* CPT only copyright 2020 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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