General Health Panel

POLICY NUMBER

L.2.04.408

DESCRIPTION

General health panel is set of laboratory tests consisting of a comprehensive metabolic panel, complete blood count (CBC), and thyroid stimulating hormone (TSH).

POLICY

General health panel is considered a not medically necessary procedure.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in this Medical Policy should not be used in lieu of the Member's specific benefit plan language.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

7/16/2009: Approved by Medical Policy Advisory Committee (MPAC)

11/24/2009: Policy Statement Section revised, replaced non-covered verbiage with "not medically necessary"

12/28/2009: Policy Guidelines section was revised to remove definition of an investigative service.

07/30/2015: Code Reference section updated for ICD-10.

06/07/2016: Policy number L.2.04.408 added. Policy Guidelines updated to add medically necessary and investigative definitions.

11/07/2022: Policy reviewed. Policy statement unchanged. Policy Guidelines updated to remove medically necessary definition.

10/18/2023: Policy reviewed; no changes.

12/05/2024: Policy reviewed; no changes.

SOURCE(S)

Centers for Medicare & Medicaid Services (CMS)

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Not Medically Necessary Codes

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