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Medical Policy: 88.88.88
Original Effective Date:
Reviewed:
Revised:
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Based on Wellmark Medical Policy, a service or treatment submitted on this claim is considered investigational or experimental and has been rejected with the Wellmark proprietary reject message E617.
Investigational (Experimental) services are determined based on procedure codes and diagnosis codes submitted on the claim as well as medical record review.
To locate a specific Medical Policy or Policies referencing the rejected service, search Wellmark Medical Policies using the CPT* code that was submitted on the rejected service line or use the narrative description of the CPT code or Procedure code in the search box.
You may also view a complete alphabetical listing of Medical Policies Wellmark has published.
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Prior Approval:
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Policy:
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Procedure Codes and Billing Guidelines:
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Selected References:
Wellmark's policy is based on:
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Policy History:
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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