Medical Policies and Clinical Utilization Management Guidelines update

Category: Medicaid

The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third Party Criteria below were developed and/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 view a guideline, visit https://www11.empireblue.com/ny_search.html.

 

Notes/updates:

Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.

• *GENE.00023 — Gene Expression Profiling of Melanomas
  • o Expanded Scope to include testing for the diagnosis of melanoma
  • o Updated INV&NMN statement to include suspicion of melanoma
• *GENE.00046 — Prothrombin G20210A (Factor II) Mutation Testing
  • o Revised title
  • o Expanded scope and position statement to include all prothrombin (factor II) variations
• *MED.00110 — Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
  • o Revised title
  • o Added new INV&NMN statements addressing Autologous adipose-derived regenerative cell therapy and use of autologous protein solution
• *SURG.00052 — Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET], Percutaneous Intradiscal Radiofrequency Thermocoagulation [PIRFT] and Intradiscal Biacuplasty [IDB])
  • o Revised title
  • o Combined the three INV&NMN statements into a single statement
  • o Added Intraosseous basivertebral nerve ablation to the INV&NMN statement
• *TRANS.00035 — Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases
  • o Revised title
  • o Expanded Position Statement to include non-hematopoietic adult stem cell therapy

• *CG-ANC-07 — Inpatient Interfacility Transfers
• Added NMN statements regarding admission and subsequent care at the receiving facility
• *CG-DME-46 — Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities
• Revised title
• Expanded Scope
• Revised MN statement to include upper extremities

• The following AIM Specialty Health® updates were approved:
  • o *Spine Surgery
  • o *Radiation Oncology-Brachytherapy Brachytherapy, intensity modulated radiation therapy (IMRT), stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) treatment guidelines
  • o Sleep Disorder Management Diagnostic & Treatment Guidelines
  • o Advanced Imaging
    • Imaging of the Heart: Cardiac CT for Quantitative Evaluation of Coronary Calcification
    • *Imaging of the Abdomen and Pelvis
  • MCG Customization for Repair of Pelvic Organ Prolapse (W0163) — Updated Coding Section

 

Medical Policies

On August 22, 2019, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire).

 

Publish date	Medical Policy number	Medical Policy title	New or revised
9/25/2019	MED.00130	Surface Electromyography Devices for Seizure Monitoring	New
8/29/2019	DRUG.00071	Pembrolizumab (Keytruda®)	Revised
8/29/2019	DRUG.00082	Daratumumab (DARZALEX®)	Revised
9/25/2019	GENE.00010	Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status Previous title: Genotype Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status	Revised
9/25/2019	GENE.00011	Gene Expression Profiling for Managing Breast Cancer Treatment	Revised
9/25/2019	GENE.00029	Genetic Testing for Breast and/or Ovarian Cancer Syndrome	Revised
8/29/2019	OR-PR.00003	Microprocessor Controlled Lower Limb Prosthesis	Revised
8/29/2019	RAD.00023	Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications	Revised
9/25/2019	SURG.00129	Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring	Revised
7/30/2019	MED.00129	Gene Therapy for Spinal Muscular Atrophy	Revised

Clinical UM Guidelines

On August 22, 2019, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines adopted by the medical operations committee for Empire members on September 26, 2019.

 

Publish date	Clinical UM Guideline number	Clinical UM Guideline title	New or revised
8/29/2019	CG-DME-47	Noninvasive Home Ventilator Therapy for Respiratory Failure	New
9/25/2019	CG-MED-84	Non-Obstetric Gynecologic Duplex Ultrasonography of the Abdomen and Pelvis in the Outpatient Setting	New
9/25/2019	CG-SURG-103	Male Circumcision	New
11/20/2019	CG-GENE-12	PIK3CA Mutation Testing	New
9/25/2019	CG-GENE-02	Analysis of RAS Status Previous title: Analysis of KRAS Status	Revised
11/20/2019	CG-MED-39	Bone Mineral Density Testing Measurement Previous title: Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry	Revised
9/25/2019	CG-MED-68	Therapeutic Apheresis	Revised
9/25/2019	CG-REHAB-08	Private Duty Nursing in the Home Setting	Revised
9/25/2019	CG-SURG-52	Level of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services	Revised
9/25/2019	CG-SURG-63	Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure	Revised
11/20/2019	CG-SURG-78	Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies Previous Title: Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies	Revised
9/25/2019	CG-SURG-79	Implantable Infusion Pumps	Revised
9/25/2019	CG-SURG-83	Bariatric Surgery and Other Treatments for Clinically Severe Obesity	Revised

 

NYE-NU-0177-19 November 2019