Previously, I published an article regarding Aetna Vitamin D Testing (click here to view it)
The following is the policy for Anthem BCBS:
Things to consider:
Is your private office practice seeing an increased number of denials for CPT code 95012? Well, maybe this is the answer why.
Some history for the CPT code 95012 first:
FENO (or NIOX) – CPT code 95012, has not been the most popular code amongst payers. In the last 5 years some payers listed in their medical policies that it was an investigational and is not considered medically necessary.
Insurance payer 1199 has paid only for 2 (TWO ) of the CPT 95012 per 1 (ONE) year. In early of 2019- payer SEIU 1199 changed its policy and is now paying for CPT 95012 when done more than 2(TWO) times per 1 (ONE) year.
However, this is about the most recent change. The change that was published on 02/27/2019 by Anthem BCBS. Local plans like TUR, MFX, MYF-are affected.
The following is the Medical Policy Position Statement:
” Investigational and Not Medically Necessary: The measurement of exhaled nitric oxide or nasal nitric oxide is considered investigational and not medically necessary in diagnosis and monitoring of asthma or other respiratory disorders.” This is followed by a lengthy rationale and the cpt codes including the CPT code 95012.
When the new healthcare reform took place so did the increase in more plans and networks that the payers, like BCBS started to offer to the members. Great! More people are covered and providers are able to see more patients.
However, the problem that the providers are running in is the fact that these plans have their own network. One of these networks is Pathway x Enhanced, offered by BCBS to the members that buy the insurance on exchange website.
Why is this a problem for the providers? Simple, Pathway X Enhanced network is exclusive to only certain 
providers that were selected for that network by the BCBS its self. But I am INN with my Local BCBS, can I join the Pathway X Enhanced network too? Unfortunately the answer to that question is NO. Why? Simply put there is a certain criteria that provider needs to meet in order to be in the Pathway X Enhanced network. You could also request the very complicated explanation from BCBS but if you have not received it in the early 2014. LOL
To avoid rejected/denied claims: train your front staff to recognize which patients have this particular coverage and double check the benefits for incoming patients BEFORE they come to the office-making sure that the incoming new patients have OON benefits and you are not incurring charges that you will have a hard time collecting.
KR2 Medical Billing 