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The HCSC Medical Policy Manual contains Medical Policies used by Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), operating through its divisions, Blue Cross and Blue Shield of Illinois, Blue Cross and Blue Shield of Montana, Blue Cross and Blue Shield of New Mexico, Blue Cross and Blue Shield of Oklahoma, and Blue Cross and Blue Shield of Texas.
Medical Policies are based on research that provides evidence of scientific merit for a particular medical technology. Technology determinations used in Medical Policies are based in part on criteria developed by the Blue Cross Blue Shield Association's Technology Evaluation Center (TEC). They are also based on data from the peer-reviewed scientific literature, from criteria developed by specialty societies and from guidelines adopted by other health care organizations. Medical Policies are used as guidelines for coverage determinations in health care benefit programs, unless otherwise indicated.
These HCSC Medical Policies apply only to members who have health insurance through the Blue Cross and Blue Shield plans of Illinois, Montana, New Mexico, Oklahoma, and Texas or who are covered by a self-insured group plan administered by these plans. If your patient is covered under a different Blue Cross and Blue Shield plan, please refer to the Medical Policies of that plan.
In the event of conflict between a Medical Policy and any plan document under which a member is entitled to Covered Services, the Plan document will govern. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.
Medical technology is constantly evolving and these Medical Policies are subject to change without notice, except as required by law. Additional Medical Policies may be developed from time to time and some may be withdrawn from use. The Medical Policies generally apply to all fully-insured benefits plans, although some local variations may exist. Additionally, some benefit plans administered by HCSC, such as some self-funded employer plans or governmental plans, may not utilize HCSC Medical Policy. Members should contact their local customer services representative for specific coverage information.
Restrictions and Limitations
The five character codes included in the Health Care Service Corporation's Medical Policy are obtained from the Physician's Current Procedural Terminology (CPT®), copyright 2012 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five character identifying codes and modifiers for reporting medical services and procedures performed by physicians. CPT is a registered trademark of the AMA.
The responsibility for the content of the Medical Policy is with the Health Care Service Corporation, and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Medical Policy. CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose.
No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of the Medical Policy should refer to the most current Physician's Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms. Applicable FARS/DFARS apply.
If you understand and agree with the terms and conditions stated above, please click "I Agree."