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Update: Policy Criteria Established
Highmark Blue Cross Blue Shield of Western New York has established new policies, new
guidelines, revised criteria for the following list of policies.
The effective date is January 1, 2024.
New Policies or Guidelines:
Policy or
Guideline
Number
Policy or Guideline Name
A-0001
Cardiac Cath and Angiography
A-0006
Renal Angiography
A-0007
Carotid or Cerebral Angiography
A-0013
Abdominal/Pelvic CT Scan
A-0014
Ankle CT Scan
A-0015
Arm CT Scan
A-0016
Brain CT Scan
A-0017
Elbow CT Scan
A-0018
Face and Sinuses CT Scan
A-0019
Foot and Foot Joints CT Scan
A-0020
Cardiac CT Scan
A-0021
Lower Extremity CT Scan
A-0022
Neck CT Scan
A-0023
Orbit and Ear CT Scan
A-0025
Cervical Spine CT Scan
A-0026
Thoracic Spine CT Scan
IN THIS ISSUE
Update: Policy Criteria Established ................................................................................................ 1
October 2023
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A-0027
Lumbar Spine CT Scan
A-0028
Chest CT Scan
A-0029
Wrist CT Scan
A-0030
Colonography, CT (Virtual Colonoscopy)
A-0031
Myelography, CT
A-0032
Abdominal/Pelvic MR Angiography (MRA)
A-0033
Head MR Angiography (MRA)
A-0034
Neck MR Angiography (MRA)
A-0035
Chest MR Angiography (MRA)
A-0036
Cardiac MR Angiography (MRA)
A-0037
Lower Extremity MR Angiography (MRA)
A-0039
Mammography
A-0044
Abdominal MRI
A-0045
Ankle MRI
A-0046
Arm MRI
A-0047
Brain MRI
A-0048
Breast MRI
A-0049
Elbow MRI
A-0050
Foot and Foot Joints MRI
A-0051
Cardiac MRI
A-0052
Knee MRI
A-0053
Lower Extremity MRI
A-0054
Neck, Orbit, and Face MRI
A-0055
Pelvic MRI
A-0056
Shoulder MRI
A-0057
Cervical Spine MRI
A-0058
Thoracic Spine MRI
A-0059
Lumbar Spine MRI
A-0061
Wrist MRI
A-0062
Temporomandibular Joint MRI
A-0064
Cholangiopancreatography, MR (MRCP)
A-0066
Gallium Scan
A-0069
Bone Scan (Bone Scintigraphy)
A-0072
Radionuclide Cystography
A-0074
Renal Cortical Scintigraphy
A-0075
Diuretic Renography
A-0077
Cardiac Radionuclide Angiography (Radionuclide Ventriculography)
A-0078
Myocardial Perfusion Imaging, Exercise Stress
A-0079
Myocardial Perfusion Imaging, Pharmacologic Stress
A-0080
Pharmacologic Stress Echocardiography
A-0081
Gastric Emptying Study (Gastric Scintigraphy)
A-0083
Hepatobiliary (Gallbladder) Scintigraphy
A-0084
Parathyroid Scan
A-0085
Thyroid Radioactive Uptake (Radioactive Iodine Uptake) (RAIU)
A-0086
Thyroid Scan
A-0087
Somatostatin Receptor Scintigraphy
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A-0088
Ventilation Perfusion Scan (VQ Scan)
A-0090
Brain, Single Photon Emission Computed Tomography (SPECT)
A-0091
Lung, Single Photon Emission Computed Tomography (SPECT)
A-0092
Esophageal Transit Scintigraphy
A-0095
Ultrasound Bone Density Measurement, Heel (Calcaneal)
A-0096
Brain Positron Emission Tomography (PET)
A-0097
Myocardial Positron Emission Tomography (PET) and PET-CT
A-0098
Tumor Imaging Positron Emission Tomography (PET) and PET-CT
A-0099
Endoscopic Ultrasound
A-0100
Abdominal Ultrasound
A-0101
Breast Ultrasound
A-0102
Hip Ultrasound
A-0103
Sonohysterography
A-0104
Renal Ultrasound
A-0105
Head and Neck Ultrasound
A-0106
Pelvic Ultrasound, Transabdominal
A-0107
Shoulder Ultrasound
A-0108
Transrectal Ultrasound
A-0109
Pelvic Ultrasound, Transvaginal
A-0111
Transthoracic Echocardiography (TTE), Resting
A-0112
Transesophageal Echocardiography TEE
A-0113
Stress Echocardiography
A-0433
Pregnant Uterus, Transabdominal Ultrasound
A-0434
Pregnant Uterus, Transvaginal Ultrasound
A-0436
Arthrography, MR
A-0437
Arthrography, CT
A-0446
Chest MRI
A-0447
Hand MRI
A-0454
Scrotal Ultrasound
A-0470
Neck CT Angiography (CTA)
A-0471
Chest CT Angiography (CTA)
A-0473
Upper Extremity CT Angiography (CTA)
A-0474
Lower Extremity CT Angiography (CTA)
A-0475
Abdominal/Pelvic CT Angiography (CTA)
A-0482
Magnetic Resonance Spectroscopy
A-0483
Cardiac CT Angiography (CTA)
A-0484
Head CT Angiography (CTA)
A-0485
Upper Extremity MR Angiography (MRA)
A-0537
Bone Marrow MRI
A-0538
Bone Mineral Density, CT
A-0539
Brain Functional MRI
A-0579
Thyroid Carcinoma Metastases Imaging
A-0640
Urography, CT (CT IVP)
A-0641
Hip CT Scan
A-0642
Hip MRI
A-0717
Intravascular Ultrasound (Coronary and Non-Coronary)
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A-1012
Hepatic Elastography, MR
X-176
Coronary Computed Topography Angiography with Selective Noninvasive
Fractional Slow Reserve
X-403
Lymphoscintigraphy
X-583
Rarely Utilized Radiology and Cardiology Procedures
X-584
Computed Tomography Perfusion Imaging of the Brain
Policies with revised criteria:
Policy
Number
Policy Name
Z-24
Miscellaneous Services
Z-67
Experimental/Investigational Services
At that time, coverage guidelines can be accessed utilizing the live link from the medical
policy website.
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We want to know what you think about our new medical policy changes. Send us an email with any
questions or comments that you may have on the new medical policies in this edition of Medical
Policy Update.
Write to us at [email protected]
Medical Policy Update is a monthly newsletter for the health care providers who participate in our networks and submit
claims to Highmark using the appropriate HIPAA transactions or claim forms as required by Highmark. This publication
focuses only on medical policy and claims administration updates, including coding guidelines and procedure code
revisions, and is the sole source for this information. For all other news, information and updates, be sure to read Provider
News, available on the Provider Resource Center at hwnybcbs.highmarkprc.com.
Highmark Blue Cross Blue Shield of Western New York is a trade name of Highmark Western and Northeastern New York
Inc., an independent licensee of the Blue Cross Blue Shield Association.
Note: This publication may contain certain administrative requirements, policies, procedures, or other similar requirements of Highmark
Inc. (or changes thereto) as well as interpretations of certain administrative requirements, policies and procedures (hereinafter
collectively “requirements”) which are binding upon Highmark Inc. and its contracted providers. Therefore, the requirements in this
publication supplement the Provider Manual. Pursuant to their contract, Highmark Inc. and such providers must comply with any
requirements included herein unless and until such item(s) are subsequently modified in whole or in part.
