Coverage Policies

Important! Please note:

Current policies effective through April 30, 2024.

Take me to policies effective May 1, 2024.

Use the index below to search for coverage information on specific medical conditions.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

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QualChoice follows care guidelines published by MCG Health.

Clinical Practice Guidelines for Providers (PDF)

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

INDEX:



Effective Date: 09/01/2008	Title: Treatment of Edema
Revision Date: 10/01/2015	Document: BI227:00
CPT Code(s): 97016
Public Statement
*Effective Date:* a) This policy will apply to all services performed on or after the above revision date which will become the new effective date. b) For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply. 1) There are many conditions causing swelling of the legs, or, occasionally, the arms. Some of these conditions are treatable and some are not. When treatment is warranted and likely to be helpful, it is subject to coverage rules; otherwise it is not covered. 2) Many times, the appropriate treatment of swelling (edema or lymphedema) requires home treatment with compression garments or compression devices. These are covered as Durable Medical Equipment – see Policy 091 for more information about the coverage of these devices. 3) Rarely, application of these devices in an office, clinic or outpatient setting may be required. This service is covered for a limited range of diagnoses and for a limited number of treatments. If the diagnosis or number of treatments recommended falls outside of the guideline, the physician or physical therapist providing the service should request preauthorization.
Medical Statement
1) The office application of vasopneumatic devices (code 97016) is covered only in the case of: a) Q82.0 – congenital edema b) R60.0 – localized edema c) I89.0 – lymphedema d) I97.2 – post-mastectomy lymphedema syndrome 2) If treatment is needed for a diagnosis code different from those listed above, preauthorization should be requested. 3) Treatment is limited to three treatments. If additional treatments are needed, the provider will need to justify the need for additional treatment by documenting unusual circumstances preventing self-treatment at home. 4) Requests for additional treatments past three will be granted only: a) In the context of a plan for transition to self-management at home; OR b) In the case that home treatment is not possible. 5) Additional treatments authorized must be handled as an override; the claims will have to be submitted to Care Management and hand carried through the claims adjudication process. Codes Used In This BI: 97016 – Vasopneumatic Device Therapy
Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.

This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.