Telehealth: Store-and-Forward Telemedicine Services

POLICY NUMBER

L.2.04.438

DESCRIPTION

“Telehealth” is the overarching umbrella of real-time clinical healthcare diagnosis, consultation and treatment provided through interactive electronic and telecommunication technologies. Telehealth encompasses Store-and-Forward Telemedicine and Remote Patient Monitoring.

Store-and-Forward Telemedicine is the use of asynchronous electronic-based communication between a patient and the consulting/referring Provider and the Provider specialist at a distant site for the purpose of diagnostic and therapeutic assistance in the care of patients who otherwise have no access to specialty care. The patient is not required to be present in real time. Store-and-Forward Telemedicine services involve the transferring of medical data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. 

Store-and-Forward Telemedicine services allow a Provider trained and licensed in his or her given specialty to review forwarded images and patient history in order to provide diagnostic and therapeutic assistance in the care of the patient without the patient being present in real time. Treatment recommendations made via electronic means will be held to the same standards as those in-person provider-patient settings. Staff involved in the Store-and-Forward Telemedicine visit must be trained in the use of the equipment and must be competent in operating the equipment. 

Related medical policy -

• Telehealth: Remote Patient Monitoring Services

• Retinal Telescreening for Diabetic Retinopathy

POLICY

All Store-and-Forward Services are subject to the provisions of the Member’s benefit plan, including Care Management.

I. Store-and-Forward Telemedicine Requirements:

1. Both the Originating Site and Distant Site Providers must be licensed in the state where the Member is located and have the appropriate equipment necessary to provide Store-and-Forward Telemedicine services, AND

2. A physician-patient relationship must be established. The Originating Site Provider must obtain the patient’s informed consent before providing Store-and-Forward Telemedicine Services. In addition to the informed consent, including risks and benefits associated with Store-and-Forward Telemedicine, the patient is to be informed of his/her right to receive follow-up care or assistance if there is an adverse treatment reaction or failure in telemedicine equipment, AND

3. The Distant Site Provider using Store-and-Forward Telemedicine must be able to offer patients the option of interactive communication upon the patient’s request. If requested by the patient, interactive communication with the distant site Provider may occur at the time of the consultation or within thirty (30) days of the patient's notification of the request of the consultation. Providers unable to offer interactive consultation shall not be reimbursed for Store-and-Forward Telemedicine services, AND

4. The telemedicine equipment must be HIPAA-compliant and sufficient to provide a review and evaluation of the data to the same standard of care required as if viewed in person, AND

5. A specialty service for Store-and-Forward is considered inaccessible to the patient, if that specialty service is unavailable to 100% of the Subscribers within a 60 mile radius of the specialty service location(s).

II. Medically Necessary Store-and-Forward Telemedicine

Store-and-Forward Telemedicine services are considered medically necessary between a patient and a distant site or originating site Provider for the purpose of diagnostic and therapeutic assistance in the care of patients who otherwise have no access to specialty care, as described in Section I.E. Accordingly, such specialty Store-and-Forward services are limited currently to the following specialties in the identified counties:

Dermatology (Coahoma, Attala, Winston, Leake)

Store-and-Forward Telemedicine services must be medically necessary subject to the provisions of the Member’s benefit plan, including not being specifically for the convenience of the Provider or the patient.

III. Services Not Considered Store-and-Forward Telemedicine

The following are not considered store-and-forward telemedicine and; therefore, are considered not medically necessary:

1. Patient-Initiated to Provider Online medical evaluation and management services, teleconsultations, or virtual visits

2. Internet-based audio-video communication between a patient and a provider, if the patient is not physically present at an originating site Telemedicine Provider (such as Skype or FaceTime)

3. Audio-only telephone or telephone conversation

4. Radiology interpretations

5. Updating medical records

6. Reporting test results

POLICY EXCEPTIONS

Federal Employee Program (FEP) Members

BlueCard Host Members: Coverage of Telemedicine Services is subject to the Member’s individual Blue Cross and/or Blue Shield benefit plan.

POLICY GUIDELINES

Refer to the Blue Cross & Blue Shield of Mississippi Telehealth Coding Policy .

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

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

1. Consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

2. Appropriate with regard to standards of good medical practice; and

3. Not solely for the convenience of the Member, his or her Provider; and

4. The most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good 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. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

12/28/2017: Telemedicine medical policy updated to separate Store-and-Forward Telemedicine and Real-Time Interactive Telemedicine coverage criteria. Policy description updated to add the definition of Telehealth. Policy statement re-written to outline coverage requirements for Store-and-Forward Telemedicine. Added names of related medical and coding policies. Policy Exceptions updated for the State and School Employees' Health Plan, Federal Employee Program (FEP) Members, and BlueCard Host Members. Sources and Code Reference sections updated.

05/17/2018: Medical and coding policy links updated.

12/21/2018: Code Reference section updated to add new 2019 HCPCS code G2010 as covered. Added CPT codes 99446, 99447, 99448, 99449, 99451, and 99452 as not medically necessary, effective 01/01/2019.

12/22/2020: Code Reference section updated to add new HCPCS code G2250, effective 01/01/2021.

07/01/2022: Policy description and policy statements updated regarding terminology: "Telemedicine Network Provider" changed to "Provider." Related medical policy links updated. Policy statements regarding Store-and-Forward Telemedicine Requirements updated with the following changes: 1) Removed statement that Store-and-Forward Telemedicine services are only covered when performed by a Blue Cross & Blue Shield of Mississippi Telemedicine Network Provider; 2) Changed "licensed in Mississippi" to "licensed in the state where the Member is located;" 3) Added that the telemedicine equipment must be "HIPAA-compliant." Policy Exceptions updated to remove State Health Plan (State and School Employees) Members. Sources updated. Code Reference section updated to remove deleted CPT code 99201.

12/21/2022: Code Reference section updated to revise the description for CPT codes 99446, 99447, 99448, 99449, and 99451, effective 01/01/2023.

08/07/2023: Policy reviewed; no changes.

08/28/2024: Policy reviewed; no changes.

12/19/2024: Code Reference section updated to add new HCPCS codes G0546, G0547, G0548, G0549, G0550, and G0551 effective 01/01/2025.

SOURCE(S)

1. Miss. Code Ann. §83-9-353

2. Miss. Code Ann. §83-9-351

3. Mississippi Administrative Code, Title 30, Part 2635, Chapter 5

4. Health Professional Shortage Area - U. S. Department of Health and Human Services’ Health Resources and Services Administration

5. Centers for Medicare & Medicaid Services Medicare Learning Network Telehealth Services Fact sheet

6. The American Telemedicine Association, Core Standards for Telemedicine Operations

CODE REFERENCE

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

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Covered Codes

Not Medically Necessary Codes 

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