Coverage Policies

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)    The hospital emergency department setting is only intended to treat patients who are experiencing a medical or psychological emergency. Emergency Department care requires any medical condition of a recent onset and severity, leading a prudent layperson to believe that the condition is of such a nature where failure to seek immediate medical care could result in placing the person’s health in serious jeopardy. An emergency situation is serious, arises quickly and threatens the life or welfare of a person. 

2)    Services rendered in the Emergency Department for non-emergent conditions are not covered.

1)    Below are examples of conditions that are not considered medical emergencies and therefore are not covered in the Emergency Department setting:

a)    Common superficial skin conditions (fungal infections, lice, scabies) (B35.0 – B36.9, B85.0 – B86)

b)    Benign skin growths/nevi (D22.0 – D23.9)

c)    Intellectual disabilities (F70 – F79)

d)    Disorders of Refraction and Accommodation (H52.0 – H52.4, H52.6, H52.7)

e)    Dental disorders:

·         Disorders of tooth development and eruption (K00.0 – K00.9)

·         Dental Caries or other non-traumatic diseases (K02.3 –  K03.9)

·         Dental infections including periapical abscess (K04.2 – K04.99)

·         Gingival and periodontal diseases (K05.00 –  K05.20, K06.010– K06.9)

·         Other diseases and conditions of teeth and supporting structures (K08.0 – K08.409, K08.421 – K09.9, M27.3)

·         Dentofacial anomalies, including malocclusion (M26.00 – M26.59)

·         Dental alveolar anomalies (M26.70 – M26.9)

f)     Chronic skin conditions or growths (psoriasis, actinic keratosis, seborrheic keratosis, corns,

Calluses (L40.0 – L40.9, L57.0 – L57.9, L82.1 – L84)

g)  Vaginitis and vulvovaginitis (N76.0 – N76.3, N77 – N77.1) if 7 years of age or older

h)    Aftercare for healing fractures or sequelae of healed fractures—as opposed to acute fractures

i)     Generally, when some circumstance or problem is present which influences the person`s health status but is not in itself a current illness or injury (Z00 – Z99). This includes wound dressing changes, care for artificial openings and ostomies, postoperative care and removal of drains, and aftercare after explantation of prosthesis. However, the following ‘Z’ diagnosis code exceptions are covered:

·         Immunizations (Z23) ONLY for Rabies vaccination (CPT 90675 – 90676) and Tetanus (CPT 90714 – 90715) in case of an injury

·         Childbirth and delivery (Z37.0 – Z38.9)

·         Persons with potential health hazards related to communicable diseases (Z20 – Z29)

·         Occupational exposure to risk factors (Z57.1 – Z57.6)

·         Exposure to hazardous chemicals (Z77.01 – Z77.098)

2)    Constipation (K59.00- K59.09) will deny for medical record review. If review of medical records determines the presenting symptoms are consistent with an acute abdomen and requires ruling out of potentially serious conditions, coverage will be approved. On the other hand, if constipation is obvious with no symptoms suggestive of a potentially serious condition, coverage will be denied. In this situation the presenting symptoms are more relevant than the final diagnosis.