State & FederalMedicaidMarch 31, 2019

Medical Policies and Clinical Utilization Management Guidelines update

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

The Medical Policies and Clinical Utilization Management (UM) Guidelines below were developed or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed. For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Please share this notice with other members of your practice and office staff.

 

To search for specific policies or guidelines, visit https://www11.empireblue.com/ny_search.html.

 

Updates:

  • CG-BEH-01 — Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome was revised to add tests for metabolic markers in the blood, urine, tissue or other biologic materials (also known as metabolomics), including but not limited to Amino Acid Dysregulation Metabotype testing as not medically necessary.
  • The following AIM Specialty Healthâ updates took effect as noted below:
    • o Musculoskeletal interventional pain management (effective January 1, 2019)
    • o Spine surgery (effective January 1, 2019)
    • o Radiology (effective November 1, 2014)
  • The following customizations to MCG Care Guidelines (22nd Edition) went into effect on January 16, 2019:
    • o Behavioral Health Level of Care Guidelines
    • o Inpatient and Surgical Care Care Guidelines — neonatology, orthopedics, thoracic surgery and pulmonary disease
  • Customizations to the MCG Care Guidelines (23rd Edition) take effect on May 24, 2019.
  • The InterQual 2019 version release takes effect on May 1, 2019.

 

Medical Policies

On November 21, 2018, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).

 

Publish date

Medical Policy #

Medical Policy title

New or revised

12/12/2018

MED.00126

Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders

New

12/12/2018

DRUG.00090

Bezlotoxumab (ZINPLAVA™)

Revised

11/15/2018

MED.00109

Corneal Collagen Cross-Linking

Revised

12/12/2018

TRANS.00024

Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome

Revised

11/15/2018

SURG.00120

Internal Rib Fixation Systems

Revised

12/12/2018

SURG.00103

Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

Revised

11/15/2018

DRUG.00046

Ipilimumab (Yervoy®)

Revised

11/15/2018

DRUG.00075

Nivolumab (Opdivo®)

Revised

12/12/2018

DRUG.00062

Obinutuzumab (Gazyva®)

Revised

11/15/2018

DRUG.00071

Pembrolizumab (Keytruda®)

Revised

12/12/2018

SURG.00121

Transcatheter Heart Valve Procedures

Revised

 

Clinical UM Guidelines

On November 21, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines were adopted by the medical operations committee for Medicaid Managed Care members on January 3, 2019.

 

Publish date

Clinical UM Guideline #

Clinical UM Guideline title

New or revised

11/15/2018

CG-DRUG-88

Dupilumab (Dupixent®)

Revised

12/12/2018

CG-BEH-01

Screening and Assessment for Autism Spectrum Disorders and Rett Syndrome

Revised

12/12/2018

CG-DRUG-107

Pharmacotherapy for Hereditary Angioedema

Revised

12/12/2018

CG-DRUG-63

Levoleucovorin Products Previously title: Levoleucovorin Calcium (Fusilev®)

Revised

12/12/2018

CG-DRUG-65

Tumor Necrosis Factor Antagonists

Revised

12/12/2018

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

Revised

12/12/2018

CG-GENE-01

Janus Kinase 2 (JAK2)V617F and JAK2 exon 12 Gene Mutation Assays Previous title: Janus Kinase 2 (JAK2) V617F Gene Mutation Assay

Revised

12/12/2018

CG-GENE-03

BRAF Mutation Analysis

Revised

12/12/2018

CG-LAB-14

Respiratory Viral Panel Testing in the Outpatient Setting

New

12/12/2018

CG-MED-78

Anesthesia Services for Interventional Pain Management Procedures

New

12/12/2018

CG-SURG-27

Sex Reassignment Surgery

Revised

12/12/2018

CG-SURG-60

Cervical Total Disc Arthroplasty

Revised

12/12/2018

CG-SURG-91

Minimally Invasive Ablative Procedures for Epilepsy

New

12/12/2018

CG-THER-RAD-03

Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

Revised

1/3/2019

CG-MED-79

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

New

1/3/2019

CG-MED-80

Positron Emission Tomography (PET) and PET/CT Fusion

New

 

PUBLICATIONS: April 2019 Empire Provider Newsletter