State & FederalMedicaidOctober 1, 2018

Medical Policies and Clinical Utilization Management Guidelines update: effective 3/22/18

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 http://www.empireblue.com/medicalpolicies/search.html.

Medical Policies

On March 22, 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* number	*Medical Policy* title	New or revised
3/29/2018	MED.00120	Voretigene neparvovec-rzyl (Luxturna™)	New
4/25/2018	SURG.00151	Balloon Dilation of Eustachian Tube	New
4/25/2018	DME.00009	Vacuum-Assisted Wound Therapy in the Outpatient Setting	Revised
3/29/2018	GENE.00028	Genetic Testing for Colorectal Cancer Susceptibility	Revised
4/25/2018	RAD.00029	CT Colonography (Virtual Colonoscopy) for Colorectal Cancer	Revised
4/25/2018	SURG.00033	Cardioverter Defibrillators	Revised
4/25/2018	SURG.00098	Mechanical Embolectomy for Treatment of Acute Stroke	Revised
4/25/2018	SURG.00121	Transcatheter Heart Valve Procedures	Revised

Clinical UM Guidelines

On March 22, 2018, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. This list represents the guidelines adopted by the medical operations committee for the Government Business Division on April 19, 2018.

Publish date	*Clinical UM Guideline* number	*Clinical UM Guideline* title	New or revised
6/28/2018	CG-BEH-15	Activity Therapy for Autism Spectrum Disorders and Rett Syndrome	New
6/22/2018	CG-DRUG-89	Implantable and Extended-Release Buprenorphine-Containing Products	New
6/28/2018	CG-DRUG-90	Intravitreal Treatment for Retinal Vascular Conditions	New
6/28/2018	CG-DRUG-91	Intravitreal Corticosteroid Implants	New
6/28/2018	CG-DRUG-92	Alpha-1 Proteinase Inhibitor Therapy	New
6/28/2018	CG-DRUG-93	Sarilumab (Kevzara®)	New
6/28/2018	CG-LAB-13	Skin Nerve Fiber Density Testing	New
6/28/2018	CG-MED-69	Inhaled Nitric Oxide	New
6/28/2018	CG-MED-70	Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule	New
6/28/2018	CG-SURG-73	Balloon Sinus Ostial Dilation	New
6/28/2018	CG-SURG-74	Total Ankle Replacement	New
6/28/2018	CG-SURG-75	Transanal Endoscopic Microsurgical Excision of Rectal Lesions	New
6/28/2018	CG-THER-RAD-07	Intravascular Brachytherapy (Coronary and Noncoronary)	New
4/25/2018	CG-SURG-31	Treatment of Keloids and Scar Revision	Revised
4/25/2018	CG-SURG-49	Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities	Revised

PUBLICATIONS: October 2018 Empire Provider Newsletter

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Provider News New York

Medical Policies and Clinical Utilization Management Guidelines update: effective 3/22/18

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