Medical Policy and Clinical Guideline updates

These updates list the new and/or revised Medical Policies and Clinical Guidelines for Empire BlueCross BlueShield (Empire). The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.

Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and Clinical Guidelines (and Medical Policy takes precedence over Clinical Guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the service is rendered must be used. This document supplements any previous Medical Policy and Clinical Guideline updates that may have been issued by Empire. Please include this update with your provider manual for future reference.

Please note that Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Empire’s Medical Policies and Clinical Guidelines can be found at https://www.empireblue.com/provider/policies/clinical-guidelines/.

Note: These updates may not apply to all administrative services only accounts as some accounts may have nonstandard benefits that apply.

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program FEP^®), visit fepblue.org > Policies & Guidelines. 

Medical Policy updates

New Medical Policies effective January 1, 2024

The following policy are new:

• MED.00144 Gene Therapy for Duchenne Muscular Dystrophy
• TRANS.00041 Molecular Microscope® Diagnostic System (MMDx) Kidney

Revised Medical Policies effective January 1, 2024

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• LAB.00011 Selected Protein Biomarker Algorithmic Assays
• LAB.00028 Blood-Based Biomarker Tests for Multiple Sclerosis
• LAB.00040 Serum Biomarker Tests for Risk of Preeclampsia
• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00071 Percutaneous and Endoscopic Spinal Surgery
• SURG.00129 Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

New Medical Policy effective January 13, 2024

The following policy is new:

• MED.00147 Cellular Therapy Products for Allogeneic Stem Cell Transplantation

Revised Medical Policies effective January 13, 2024

The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational:

• SURG.00026 Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00144 Occipital and Sphenopalatine Ganglion Nerve Block Therapy for the Treatment of Headache and Neuralgia
• TRANS.00039 Portable Normothermic Organ Perfusion Systems

Clinical Guideline updates

Revised Clinical Guideline effective January 1, 2024

The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity

Revised Clinical Guidelines effective January 13, 2024

The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CG-MED-88 Preimplantation Embryo Biopsy and Genetic Testing
• CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices