UPMC Health Plan POLICY AND PROCEDURE MANUAL :

UPMC Health Plan
POLICY AND PROCEDURE MANUAL
POLICY NUMBER: PAY.087
REVISION DATE: 12/13
ANNUAL APPROVAL DATE: 02/14
PAGE NUMBER: 1 of 13
SUBJECT:
INDEX TITLE:
ORIGINAL DATE:
Intraoperative Neurophysiological Testing
Medical Management
February 2010
This policy applies to the following lines of business: (Check those that apply.)
COMMERCIAL
CMS-MA
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ANCILLARY
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Dental ( )
PPO ( )
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I.
POLICY
It is the policy of UPMC Insurance Services Division to cover Intraoperative
Neurophysiological Testing (IONT) when it is medically necessary as detailed in this
policy and covered under the member’s specific benefit plan.
II.
DEFINITIONS
Clinically Trained Neurophysiologist is a physician (MD or DO) board certified in
Neurology or Neurosurgery who has completed an accredited fellowship in clinical
neurophysiology and/or intraoperative neurophysiological monitoring.
III.
PURPOSE
The purpose of this policy is to determine the indications for coverage of Intraoperative
Neurophysiological Testing.
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IV.
SCOPE
This policy applies to various UPMC Insurance Services Division Departments as
indicated by the Benefit and Reimbursement Committee. These include but are not
limited to Medical Management, Benefit Configuration and Claims Departments.
V.
PROCEDURE
A. Medical Description / Background
Intraoperative neurophysiological testing describes ongoing electrophysiologic testing
and monitoring performed during surgical procedures on the nervous system, its blood
supply, or adjacent tissue to prevent unintentional damage to critical neurologic
structures. It is a recognized medical practice standard for almost 30 years although
randomized controlled trials establishing efficacy of it have not been done.
Intraoperative neurophysiological monitoring (IONM) consists of the use of
electroencephalography (EEG), evoked potentials (such as cranial nerve, brain-stem
auditory, motor or somatosensory EP’s), and/or electromyography (EMG) to monitor the
function of neural structures. The goal is to identify changes in the brain, spinal cord,
and peripheral nerve function prior to irreversible damage. It is also used to localize
anatomical structures which help guide the surgeon during dissection and can
demonstrate which nerves are still functional versus compromised.
Monitoring, if used to assess sensory/motor pathways, should access the appropriate
pathway because inappropriate monitoring could result in an adverse outcome. Some
high risk patients may only be approved for surgery if IONM is performed. IONM may
be used in neurosurgery, orthopedic, vascular, cardiothoracic, and other surgical
specialties. The quality, extent, and type of monitoring are dependent on the nature and
location of the surgery or lesions. IONM by non-physician personnel (a specifically
trained technician registered with one of the credentialing organizations such as the
American Board of Neurophysiology Monitoring or the American Board of Registration
of Electrodiagnostic Technologists) must be performed under the direct supervision of a
physician trained in neurophysiologic techniques who is available to interpret the studies
and advise the surgeon during the operative procedure.
B. Indications include ANY of the following:
•
•
•
•
Surgery of the aortic arch, its branch vessels, or thoracic aorta, including carotid
artery surgery, when there is a risk of cerebral or spinal cord ischemia
Resection of epileptogenic brain tissue or tumor
Resection of brain tissue close to the primary motor cortex and requiring brain
mapping
Protection of cranial nerves:
1. tumors that affect optic, trigeminal, facial, auditory nerves
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
2. cavernous sinus tumors
3. microvascular decompression of cranial nerves
4. oval or round window graft
5. endolymphatic shunt for Meniere’s disease
6. vestibular section for vertigo
7. laryngeal nerve for thyroid surgeries
Correction of scoliosis or deformity of spinal cord involving traction on the cord
Protection of spinal cord where work is performed in close proximity to cord as in
the placement or removal of old hardware or where there have been numerous
interventions
Spinal instrumentation requiring pedicle screws or distraction
Decompression procedures on the spinal cord or cauda equine carried out for
myelopathy or claudication where function of spinal cord or spinal nerves is at
risk
Spinal cord tumors
Neuromas of peripheral nerves of brachial plexus, when there is risk to major
sensory or motor nerves
Surgery or embolization for intracranial arteriovenous AV malformations
Surgery for arteriovenous malformation of spinal cord
Cerebral vascular aneurysms
Surgery for intractable movement disorders
Arteriography, during which there is a test occlusion of the carotid artery
Circulatory arrest with hypothermia (does not include surgeries performed under
circulatory bypass (e.g., CABG, ventricular aneurysms)
Distal aortic procedures, where there is risk of ischemia to spinal cord
Leg lengthening procedures, where there is traction on sciatic nerve or other nerve
trunks
Basal ganglia movement disorders
Surgery as a result of traumatic injury to spinal cord/brain
Deep brain stimulation
C. Limitations include all of the following:
•
The test must be requested by the operating surgeon and the monitoring must be
performed by a clinically trained neurophysiologist (MD/DO) other than the
operating surgeon, the surgical assistant, or the anesthesiologist rendering the
anesthesia due to the high potential for morbidity. Claims submission must
include documentation for the time devoted to direct monitoring of the
patient (time may be cumulative).
•
A technologist must be present continuously in the operating suite recording and
monitoring a single case under the neurophysiologist’s supervision. This
technologist must have either the physical or electronic capacity for real-time
communication with the supervising neurophysiologist.
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•
The surgical team and the monitoring staff must always be able to be in
immediate contact with each other.
•
Services must be performed in the inpatient setting only.
•
Intraoperative monitoring is not medically necessary in situations where historical
data and current practices reveal no potential to neural integrity during surgery.
•
For coverage of remote monitoring (as mentioned above) the neurophysiologist
must have immediate physical or real-time communication with the operating
room. He/she must have the ability to watch the tracings as they are obtained in
real-time in the operating room as well as the baseline electrophysiological test
and the monitoring tracings from earlier in the case.
•
The monitoring physician must have a plan in place to transfer care to another
physician, should any other situation arise during patient monitoring.
•
Technical criteria – it is mandatory that at least 8 recording channels (16 if EEG is
monitored) be available for all IONM. The equipment utilized must also provide
for all of the monitoring modalities that are needed such as auditory-evoked
response, electroencephalography/electrocorticography, electromyography/nerve
conduction, and somatosensory-evoked response.
D. Codes
The following codes for treatments and procedures applicable to this policy are included
below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or
device code(s) does not constitute or imply member coverage or provider reimbursement
policy. Please refer to the member's contract benefits in effect at the time of service to
determine coverage or non-coverage of these services as it applies to an individual
member.
CPT Coding:
CPT Code:
95940
*95941
G0453
Description:
Continuous intraoperative neurosphysiology monitoring in the
operating room, one on one monitoring requiring personal
attendance, each 15 minutes (List separately in addition to code for
primary procedure and in conjunction with the study performed)
Continuous intraoperative neurosphysiology monitoring, from
outside the operating room (remote or nearby) or for monitor of
more than one case within in the operating room, per hour (List
separately in addition to code for primary procedure and in
conjunction with the study performed)
Continuous intraoperative neurophysiology monitoring, from outside
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the operating room (remote or nearby), per patient, (attention
directed exclusively to one patient each 15 minutes (List in addition
to primary procedure.
*CPT Code 95941 is invalid for Medicare*
ICD Coding
ICD-9 Code:
170.2
192.0-192.9
193
198.3
198.4
225.0-225.9
237.0
237.1
237.5
237.6
237.7-237.72
237.9
239.6
246.9
324.1
336.0
343.8
343.9
348.4
350.1
350.2
352.0-352.9
353.0
353.1
353.2
353.3
353.4
385.30-385.35
430
431
432.0-432.9
Description:
Malignant neoplasm of vertebral column excluding sacrum and
coccyx
Malignant neoplasm of cranial nerves-malignant neoplasm of
nervous system part unspecified
Malignant neoplasm of thyroid gland
Secondary malignant neoplasm of brain and spinal cord
Secondary malignant neoplasm of other parts of nervous system
Benign neoplasm of brain-benign neoplasm of nervous system
unspecified
Neoplasm of uncertain behavior of pituitary gland and
craniopharyngeal duct
Neoplasm of uncertain behavior of pineal gland
Neoplasm of uncertain behavior of brain and spinal cord
Neoplasm of uncertain behavior of meninges
Neurofibromatosis unspecified-Neurofibromatosis type 2 acoustic
neurofibromatosis
Neoplasm of uncertain behavior of other and unspecified parts of
nervous system
Neoplasm of unspecified nature of brain
Unspecified disorder of thyroid
Intraspinal abscess
Syringomyelia and syringobulbia
Other specified infantile cerebral palsy
Infantile cerebral palsy unspecified
Compression of brain
Trigeminal neuralgia
Atypical face pain
Disorders of cranial nerves
Brachial plexus lesions
Lumbosacral plexus lesions
Cervical root lesions, not elsewhere classified
Thoracic root lesions not elsewhere classified
Lumbosacral root lesions not elsewhere classified
Cholesteatoma unspecified-Diffuse cholesteatosis of middle ear and
mastoid
Subarachnoid hemorrhage
Intracerebral hemorrhage
Nontraumatic extradural hemorrhage-unspecified intracranial
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433.00-433.91
434.00-434.91
435.0-435.9
437.3
437.5
441.00-441.03
441.1-441.9
443.21
443.24
721.1
721.41-721.42
721.91
722.70-722.73
723.0
724.00-724.09
737.10-737.19
737.20
737.22
737.30-737.39
737.40-737.43
737.8
741.00-741.03
747.81
747.82
767.4
767.5
767.6
767.7
806.01-806.09
806.10-806.19
806.20-806.29
hemorrhage
Occlusion and stenosis of basilar artery without cerebral infarctionocclusion and stenosis of unspecified precerebral artery with
cerebral infarction
Cerebral thrombosis without cerebral infarction-cerebral artery
occlusion unspecified with cerebral infarction
Basilar artery syndrome-unspecified transient cerebral ischemia
Cerebral aneurysm nonruptured
Moyamoya disease
Dissection of aorta aneurysm unspecified site-Dissection of aorta
thoracoabdominal
Thoracic aneurysm ruptured-aortic aneurysm of unspecified site
without rupture
Dissection of carotid artery
Dissection of vertebral artery
Cervical spondylosis with myelopathy
Spondylosis with myelopathy thoracic region-spondylosis with
myelopathy lumber region
Spondylosis of unspecified site with myelopathy
Intervertebral disc disorder with myelopathy unspecifiedintervertebral disc disorder with myelopathy lumbar region
Spinal stenosis of in cervical region
Spinal stenosis other than cervical
Kyphosis (acquired) (postural) - other kyphosis acquired
Lordosis (acquired) (postural)
Other postsurgical lordosis
Scoliosis (and kyphoscoliosis) idiopathic-other kyphoscoliosis and
scoliosis
Unspecified curvature of spine associated with other conditionsscoliosis associated with other conditions
Other curvatures of spine associated with other conditions
Spina bifida unspecified region with hydrocephalus-spina bifida
lumbar region with hydrocephalus
Congenital anomalies of cerebrovascular system
Spinal vessel anolmaly
Injury to spine and spinal cord due to birth trauma
Facial nerve injury due to birth trauma
Injury to brachial plexus due to birth trauma
Other cranial and peripheral nerve injuries due to birth trauma
Closed fracture of C1-C4 level with complete lesion of cord-closed
fracture of C5-C7 level with other specified spinal cord injury
Open fracture of C1-C4 level with unspecified spinal cord injuryopen fracture of C5-C7 level with other specified spinal cord injury
Closed fracture of T1-T6 level with unspecified spinal cord-closed
fracture of T7-T12 level with other specified spinal cord injury
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806.30-806.39
806.4
806.5
806.7-806.79
806.8
806.9
850.4
953.0-953.9
955.0-955.9
956.0-956.9
ICD-10 Code:
C41.2
C72.0-C72.9
Open fracture of T1-T6 level with unspecified spinal cord injuryopen fracture of T7-T12 level with other specified spinal cord injury
Closed fracture of lumbar spine with spinal cord injury
Open fracture of lumbar spine with spinal cord injury
Open fracture of sacrum and coccyx with unspecified spinal cord
injury-open fracture of sacrum and coccyx with other spinal cord
injury
Closed fracture of unspecified vertebra with spinal cord injury
Open fracture of unspecified vertebra with spinal cord injury
Concussion with prolonged loss of consciousness without return to
pre-existing conscious level
Injury to cervical nerve root- injury to unspecified site of nerve roots
and spinal plexus
Injury to axillary nerve-injury to unspecified nerve of shoulder
girdle and upper limb
Injury to sciatic nerve- injury to unspecified nerve of pelvic girdle
and lower limb
D49.9
E07.89
G06.1
Description:
Malignant neoplasm of vertebral column
Malignant neoplasm of spinal cord, cranial nerves, and other parts
of central nervous system
Malignant neoplasm of thyroid gland
Secondary malignant neoplasm of brain and other parts of nervous
system
Benign neoplasm for meninges, brain, and other parts of central
nervous system
Neoplasm of uncertain behavior of pituitary, craniopharyngeal,
and pineal glands-Neoplasm of uncertain behavior of carotid body,
aortic body, and other paraganglia
Neoplasm of uncertain behavior of brain and central nervous
system
Neoplasm of unspecified behavior of brain
Other specified disorders of thyroid
Intraspinal abscess and granuloma
G45.0
G45.1
G45.8
G45.9
G50.0
G50.1
G52.0-G52.9
G53
G54.0
G54.1
Vertebro-basilar artery syndrome
Carotid artery syndrome (hemispheric)
Other transient cerebral ischemic attacks and related syndromes
Transient cerebral ischemic attack, unspecified
Trigeminal neuralgia
Atypical facial pain
Disorders of cranial nerves
Cranial nerve disorders in diseases classified elsewhere
Brachial plexus disorders
Lumbosacral plexus disorders
C73
C79.3-C79.49
D32.0-D33.9
D44.3-D44.7
D43.0-D43.9
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G54.2
G54.3
G54.4
G80.8
G80.9
G93.5
G95.0
H71.93
H71.03
H71.13
H74.40
H71.23
H71.33
I60.9
I61.9
I62.00
I62.1
I62.9
I63.019
I63.119
I63.139
I63.20
I63.219
I63.22
I63.239
I63.30
I63.40
I63.50
I63.59
I65.09
I65.1
I65.29
I65.8
I65.9
I66.09
I66.19
I66.29
Cervical root disorders, not elsewhere classified
Thoracic root disorders, not elsewhere classified
Lumbosacral root disorders, not elsewhere classified
Other cerebral palsy
Cerebral palsy, unspecified
Compression of brain
Syringomyelia and syringobulbia
Unspecified cholesteatoma, bilateral
Cholesteatoma of attic, bilateral
Cholesteatoma of tympanum, bilateral
Polyp of middle ear, unspecified ear
Cholesteatoma of mastoid, bilateral
Diffuse cholesteatosis, bilateral
Nontraumatic subarachnoid hemorrhage, unspecified
Nontraumatic intracerebral hemorrhage, unspecified
Nontraumatic subdural hemorrhage, unspecified
Nontraumatic extradural hemorrhage
Nontraumatic intracranial hemorrhage, unspecified
Cerebral infarction due to thrombosis of unspecified vertebral
artery
Cerebral infarction due to embolism of unspecified vertebral artery
Cerebral infarction due to embolism of unspecified carotid artery
Cerebral infarction due to unspecified occlusion or stenosis of
unspecified precerbral arteries
Cerebral infarction due to unspecified occlusion or stenosis of
unspecified vertebral arteries
Cerebral infarction due to unspecified occlusion or stenosis of
basilar arteries
Cerebral infarction due to unspecified occlusion or stenosis of
unspecified carotid arteries
Cerebral infarction due to thrombosis of unspecified cerebral
artery
Cerebral infarction due to embolism of unspecified cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of
unspecified cerebral artery
Cerebral infarction due to unspecified occlusion or stenosis of
other cerebral artery
Occlusion and stenosis of unspecified vertebral artery
Occlusion and stenosis of basilar artery
Occlusion and stenosis of unspecified carotid artery
Occlusion and stenosis of other precerebral arteries
Occlusion and stenosis of unspecified precerebral artery
Occlusion and stenosis of unspecified middle cerebral artery
Occlusion and stenosis of unspecified anterior cerebral artery
Occlusion and stenosis of unspecified posterior cerebral artery
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I66.9
I67.1
I67.848
I67.5
I71.00
I71.01
I72.02
I71.03
I71.1
I71.2
I71.3
I71.4
I71.5
I71.6
I71.8
I71.9
I77.71
I77.74
M40.00
M40.10
M40.209
M40.299
M40.40
M40.50
M41.00
M41.20
M41.30
M41.40
M41.50
M41.80
M41.9
M43.8X9
M47.10
M47.12
M47.14
M47.16
M48.00-M48.08
M50.00
M51.04
M51.05
M51.06
M51.9
M96.2
Occlusion and stenosis of unspecified cerebral artery
Cerebral aneurysm, nonruptured
Other cerebrovascular vasospasm and vasoconstriction
Moyamoya disease
Dissection of unspecified site of aorta
Dissection of thoracic aorta
Dissection of abdominal aorta
Dissection of thoracoabdominal aorta
Thoracic aortic aneurysm, ruptured
Thoracic aortic aneurysm, without rupture
Abdominal aortic aneurysm, ruptured
Abdominal aortic aneurysm, without rupture
Thoracoabdominal aortic aneurysm, ruptured
Thoracoabdominal aortic aneurysm, without rupture
Aortic aneurysm of unspecified site, ruptured
Aortic aneurysm of unspecified site, without rupture
Dissection of carotid artery
Dissection of vertebral artery
Postural kyphosis, site unspecified
Other secondary kyphosis, site unspecified
Unspecified kyphosis, site unspecified
Other kyphosis, site unspecified
Postural lordosis, site unspecified
Lordosis, unspecified, site unspecified
Infantile idiopathic scoliosis, site unspecified
Other idio9pathic scoliosis, site unspecified
Thoracogenic scoliosis, site unspecified
Neuromuscular scoliosis, site unspecified
Other secondary scoliosis, site unspecified
Other forms of scholiosis, site unspecified
Scoliosis, unspecified
Other specified deforming dorsopathies, site unspecified
Other spondylosis with myelopathy, site unspecified
Other spondylosis with myelopathy, cervical region
Other spondylosis with myelopathy, thoracic region
Other spondylosis with myelopathy, lumbar region
Spinal stenosis
Cervical disc disorder with myelopathy, unspecified cervical
region
Intervertebral disc disorders with myelopathy, thoracic region
Intervertebral disc disorders with myelopathy, thoracolumbar
region
Intervertebral disc disorders with myelopathy, lumbar region
Unspecified thoracic, thoracolumbar and lumbosacral
intervertebral disc disorder
Postradiation kyphosis
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M96.3
M96.4
M96.5
Q05.0
Q05.1
Q05.2
Q05.4
Q07.01
Q07.02
Q07.03
Q27.9
Q28.2
Q28.3
Q85.0-Q85.09
P11.3
P11.5
P14.0
P14.1
P14.3
S06.0X6DS06.0X6S
S12.000AS12.9XXS
S14.0XXAS14.9XXS
S22.000AS22.089S
S24.0XXAS24.9XXS
S32.000AS32.059S
S32.10XAS32.2XXS
S34.01XAS34.01XS
S34.02XAS34.03XS
S34.101AS34.124S
S34.131AS34.139S
S34.21XAS34.9XXS
S44.00XAS44.92XS
Postlaminectomy kyphosis
Postsurgical lordosis
Postradiation scoliosis
Cervical spinda bifida with hydrocephalus
Thoracic spina bifida with hydrocephalus
Lumbar spina bifida with hydrocephalus
Unspecified spina bifida with hydrocephalus
Arnold-Chiari syndrome with spina bifida
Arnold-Chiari syndrome with hydrocephalus
Arnold-Chiari syndrome with spina bifida and hydrocephalus
Congenital malformation of peripheral vascular system,
unspecified
Arteriovenous malformation of cerebral vessels
Other malformations of cerebral vessels
Neurofibromatosis
Birth injury to facial nerve
Birth injury to spine and spinal cord
Erb’s paralysis due to birth injury
Klumpke’s paralysis due to birth injury
Other brachial plexus birth injuries
Concussion with loss of consciousness without return to preexisting conscious level (greater than 24 hours)
Fracture of cervical vertebra and other parts of neck
Injury of nerves and spinal cord at neck level
Fracture of the thoracic vertebra
Injury of nerves and spinal cord at thorax level
Open/closed fractures of lumbar spine
Open/closed fractures of sacrum and coccyx
Concussion and edema of lumbar spinal cord
Concussion and edema of sacral spinal cord
Injuries of lumbar spine and spinal cord
Injuries of sacral spine and spinal cord
Injuries of nerve root of lumber, sacral, and unspecified nerves at
abdomen
Injuries of nerves at shoulder and upper arm level
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S74.00XAS74.92.XS
Injuries of sciatic verve and nerves at hip and thigh level
E. Variations
N/A
F. Quality Audit
Quality Audit monitors policy compliance and/or billing accuracy at the request of the
UPMC Insurance Services Division’s Technology Assessment Committee or the Benefits
Reimbursement Committee.
G. Records Retention
Records Retention for documents, regardless of medium, are provided within the UPMC
Health System Policy for Records Retention, Management and Retirement, and as
indicated in the UPMC Insurance Services Division Policy and Procedure for Records
Retention.
Unless otherwise mandated by Federal or State law, or unless required to be maintained
for litigation purposes, any communications recorded pursuant to this Policy are
maintained for a minimum of ten (10) years from the date of recording.
H. References
Medical Literature/Clinical Information:
1. American Academy of Neurology (AAN). Evidence-based Guideline Update:
Intraoperative Spinal Monitoring with Somatosensory and Transcranial Electrical
Motor Evoked Potentials-Author Replies, July 16, 2012.
http://www.neurology.org/content/79/3/292.full.pdf+html
2. American Society of Electroneurodiagnostic Technologists (ASET). ASET – The
Neurodiagnostic Society. Position Statement: Unattended Intraoperative
Neurophysiologic Monitoring, March 2012.
http://www.aset.org/files/public/Unattended_Monitoring_Statement_March_2012
.pdf
3. Nuwer, M.R., Emerson, R.G. Galloway, G., Legatt, A.D., Lopez, J., Minahan, R.,
Yamada, T., Goodin, D.S., Armon, C., Chaudhry, V., Gronseth, G.S., & Harden,
C.L., Evidence-based Guideline Update: Intraoperative Spinal Monitoring with
Somatosensory and Transcranial Electrical Motor Evoked Potentials-American
Academy of Neurology (AAN): Neurology, February 20, 2012.
http://www.neurology.org/content/78/8/585.full.pdf+html
4. American Academy of Neurology (AAN). Principles of Coding for
Intraoperative Neurophysiologic Monitoring and Testing- AAN Model Medical
Policy. Approved February 10, 2012.
http://patients.aan.com/globals/axon/assets/9339.pdf
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5. American Medical Association- House of Delegates. June 2008 - Annual
Meeting. Resolution 201- Intraoperative Neurophysiologic Monitoring. Page
490.. http://www.ama-assn.org/resources/doc/hod/a08resolutions.pdf
Regulatory/Government Source:
1. Centers for Medicare and Medicaid Services (CMS). Local Coverage
Determination (LCD) No. L27499 – Intraoperative Neurophysiological Testing.
(Contractor: Novitas Solutions). Revision Effective Date: 01/01/2013.
http://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=27499&ContrId=165&ver=53&ContrVer=2&CntrctrSelecte
d=165*2&Cntrctr=165&name=Novitas+Solutions%2c+Inc.+(12501%2c+MAC++Part+A)&s=45&DocType=All&bc=AggAAAIAAAAAAA%3d%3d&
2. National Guideline Clearinghouse- Evidence-based Guideline Update:
Intraoperative Spinal Monitoring with Somatosensory and Transcranial Electrical
Motor Evoked Potentials, February 21, 2012.
http://www.guideline.gov/content.aspx?id=36896&search=intraoperative+neurop
hysiologic+monitoring
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Disclaimer: UPMC Health Plan medical payment and prior authorization policies do not
constitute medical advice and are not intended to govern or otherwise influence the
practice of medicine. The policies constitute only the reimbursement and coverage
guidelines of UPMC Health Plan and its affiliated managed care entities. Coverage for
services varies for individual members in accordance with the terms and conditions of
applicable Certificates of Coverage, Summary Plan Descriptions, or contracts with
governing regulatory agencies.
UPMC Health Plan reserves the right to review and update the medical payment and prior
authorization guidelines in its sole discretion. Notice of such changes, if necessary, shall
be provided in accordance with the terms and conditions of provider agreements and any
applicable laws or regulations.
These policies are the proprietary information of UPMC Health Plan. Any sale, copying,
or dissemination of said policies is prohibited.
Proprietary and Confidential Information of UPMC Health Plan
© 2014 UPMC All Rights Reserved