State & FederalMedicaidOctober 1, 2018

Medical Policies and Clinical Utilization Management Guidelines update: effective 1/25/18

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

Medical Policies update

On January 25, 2018, the medical policy and technology assessment committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire). These policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing.

 

The Medical Policies were made publicly available on our provider website on the effective date listed. To search for specific policies, visit http://www.empireblue.com/medicalpolicies/search.html.

 

Please note:

  • Starting July 1, 2018, AIM Specialty Health® Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.
  • For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

Publish date

Medical Policy number

Medical Policy title

New or revised

2/28/2018

DRUG.00116

Vestronidase alfa (Mepsevii™)

New

2/28/2018

DRUG.00046

Ipilimumab (Yervoy®)

Revised

2/28/2018

DRUG.00075

Nivolumab (Opdivo®)

Revised

2/28/2018

DRUG.00077

Monoclonal Antibodies to Interleukin-17A

Revised

2/1/2018

DRUG.00080

Monoclonal Antibodies for the Treatment of Eosinophilic Conditions

Revised

2/28/2018

DRUG.00082

Daratumumab (DARZALEX™)

Revised

2/28/2018

DRUG.00099

Cerliponase Alfa (Brineura™)

Revised

2/28/2018

GENE.00028

Genetic Testing for Colorectal Cancer Susceptibility

Revised

2/1/2018

GENE.00029

Genetic Testing for Breast and/or Ovarian Cancer Syndrome

Revised

2/28/2018

GENE.00035

Genetic Testing for TP53 Mutations

Revised

2/28/2018

MED.00100

Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems

Revised

2/1/2018

SURG.00011

Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

Revised

2/1/2018

SURG.00098

Mechanical Embolectomy for Treatment of Acute Stroke

Revised

2/28/2018

SURG.00145

Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

Revised

Clinical Utilization Management Guidelines update

On January 25, 2018, the MPTAC approved the following Clinical Utilization Management (UM) Guidelines applicable to Empire. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the following listing. This list represents the Clinical UM Guidelines adopted by the medical operations committee for the Government Business Division on March 2, 2018.

 

The clinical guidelines were made publicly available on our provider website on the effective date listed. To search for specific guidelines, visit http://www.empireblue.com/medicalpolicies/search.html.

 

Please note:

  • Starting July 1, 2018, AIM Specialty Health® Cardiology and Radiation Oncology Guidelines are utilized for clinical reviews.
  • For markets with carved-out pharmacy services, the applicable listings below are informational only.

 

Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff.

 

Publish date

Clinical UM Guideline number

Clinical UM Guideline title

New or revised

5/1/2018

CG-DME-42

Nonimplantable Insulin Infusion and Blood Glucose Monitoring Devices

New

5/1/2018

CG-DME-43

High-Frequency Chest Compression Devices for Airway Clearance

New

5/1/2018

CG-DRUG-82

Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension

New

5/1/2018

CG-DRUG-83

Growth Hormone

New

5/1/2018

CG-DRUG-84

Belimumab (Benlysta®)

New

5/1/2018

CG-DRUG-85

Tesamorelin (Egrifta®)

New

5/1/2018

CG-DRUG-86

Ocriplasmin (Jetrea®) Intravitreal Injection Treatment

New

5/1/2018

CG-DRUG-87

Vedolizumab (Entyvio®)

New

5/1/2018

CG-DRUG-88

Dupilumab (Dupixent®)

New

5/1/2018

CG-SURG-70

Gastric Electrical Stimulation

New

5/1/2018

CG-SURG-71

Reduction Mammaplasty

New

5/1/2018

CG-SURG-72

Endothelial Keratoplasty

New

7/1/2018

CG-THER-RAD-03

Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy

New

7/1/2018

CG-THER-RAD-04

Selective Internal Radiation Therapy of Primary or Metastatic Liver Tumors

New

5/1/2018

CG-DRUG-29

Hyaluronan Injections

Revised

2/28/2018

CG-DRUG-50

Paclitaxel, protein bound (Abraxane®)

Revised

2/28/2018

CG-DRUG-59

Testosterone Injectable

Revised

2/28/2018

CG-DRUG-73

Denosumab (Prolia®, Xgeva®)

Revised

2/28/2018

CG-DRUG-78

Antihemophilic Factors and Clotting Factors

Revised

2/28/2018

CG-MED-39

Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry

Revised

2/28/2018

CG-MED-53

Cervical Cancer Screening Using Cytology and Human Papillomavirus Testing

Revised

2/28/2018

CG-SURG-33

Lumbar Fusion and Lumbar Total Disc Arthroplasty

Revised

PUBLICATIONS: October 2018 Empire Provider Newsletter