Medical policy and clinical guideline updates

Material Adverse Change (MAC)

 

These updates list the new and/or revised Empire BlueCross BlueShield (“Empire”) medical policies, clinical guidelines and reimbursement policies*.  The implementation date for each policy or guideline is noted for each section.  Implementation of the new or revised medical policy, clinical guideline or reimbursement policy 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 services are 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 empireblue.com.

 

*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.

 

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.

 

Medical policy updates

 

Revised medical policy effective March 12, 2022

(The following policy was revised to expand medical necessity indications or criteria.)

• SURG.00036 Fetal Surgery for Prenatally Diagnosed Malformations

 

Revised medical policies effective April 1, 2022

(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)

• DME.00043 Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
• GENE.00023 Gene Expression Profiling of Melanomas
• GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy)
• LAB.00036 Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
• SURG.00153 Cardiac Contractility Modulation Therapy

 

Revised medical policy effective April 1, 2022

(The following policy was revised to expand medical necessity indications or criteria.)

• SURG.00011 Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting

 

Revised medical policy effective April 1, 2022

(The following policy was reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)

• LAB.00015 Detection of Circulating Tumor Cells

 

Archived medical policy effective April 13, 2022

(The following policy has been archived and its contents have been transferred to a new Medical Policy and to an existing Clinical UM Guideline.)

• GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease [Note: Content for biomarker testing for Alzheimer's Disease moved to new medical policy LAB.00046 Biochemical Markers for Alzheimer's Disease. Content for gene testing for Alzheimer's Disease moved to CG-GENE-13 Genetic Testing for Inherited Diseases.]

 

Transitioned medical policy effective April 13, 2022

(The following policy was previously in another medical policy and has no significant changes.)

• LAB.00046 Biochemical Markers for Alzheimer's Disease [Note: Moved content related to biomarker testing for Alzheimer’s disease (AD) from GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.]

 

Revised medical policy effective April 13, 2022

(The following policy was revised to expand medical necessity indications or criteria.)

• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling [Note: Moved content for measurable residual disease testing to CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing]

 

Revised medical policies effective April 13, 2022

(The following policies were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)

• ANC.00008 Cosmetic and Reconstructive Services of the Head and Neck
• DME.00022 Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
• DME.00032 Automated External Defibrillators for Home Use
• DME.00041 Low Intensity Therapeutic Ultrasound
• GENE.00009 Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
• GENE.00038 Genetic Testing for Statin-Induced Myopathy
• GENE.00050 Gene Expression Profiling for Coronary Artery Disease
• GENE.00054 Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
• GENE.00056 Gene Expression Profiling for Bladder Cancer
• LAB.00025 Topographic Genotyping
• LAB.00033 Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
• LAB.00038 Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
• LAB.00039 Pooled Antibiotic Sensitivity Testing
• MED.00011 Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
• MED.00024 Adoptive Immunotherapy and Cellular Therapy
• MED.00053 Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
• MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
• MED.00059 Idiopathic Environmental Illness (IEI)
• MED.00087 Optical Detection for Screening and Identification of Cervical Cancer
• MED.00101 Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
• MED.00102 Ultrafiltration in Decompensated Heart Failure
• MED.00104 Non-invasive Measurement of Advanced Glycation End Products (AGEs) in the Skin
• MED.00105 Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
• MED.00111 Intracardiac Ischemia Monitoring
• MED.00112 Autonomic Testing
• MED.00118 Continuous Monitoring of Intraocular Pressure
• MED.00120 Gene Therapy for Ocular Conditions
• MED.00125 Biofeedback and Neurofeedback
• RAD.00038 Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
• RAD.00044 Magnetic Resonance Neurography
• RAD.00052 Positional MRI
• RAD.00059 Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
• SURG.00043 Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
• SURG.00053 Unicondylar Interpositional Spacer
• SURG.00056 Transanal Radiofrequency Treatment of Fecal Incontinence
• SURG.00061 Presbyopia and Astigmatism-Correcting Intraocular Lenses
• SURG.00070 Photocoagulation of Macular Drusen
• SURG.00072 Lysis of Epidural Adhesions
• SURG.00075 Intervertebral Stabilization Devices
• SURG.00089 Self-Expanding Absorptive Sinus Ostial Dilation
• SURG.00103 Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
• SURG.00113 Artificial Retinal Devices
• SURG.00124 Carotid Sinus Baroreceptor Stimulation Devices
• SURG.00132 Drug-Eluting Devices for Maintaining Sinus Ostial Patency
• SURG.00137 Focused Microwave Thermotherapy for Breast Cancer
• SURG.00139 Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
• SURG.00140 Peripheral Nerve Blocks for Treatment of Neuropathic Pain
• SURG.00148 Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
• SURG.00149 Percutaneous Ultrasonic Ablation of Soft Tissue
• SURG.00150 Leadless Pacemaker
• SURG.00151 Balloon Dilation of the Eustachian Tubes
• SURG.00152 Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
• SURG.00159 Focal Laser Ablation for the Treatment of Prostate Cancer
• TRANS.00004 Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
• TRANS.00011 Pancreas Transplantation and Pancreas Kidney Transplantation
• TRANS.00013 Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
• TRANS.00016 Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
• TRANS.00028 Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
• TRANS.00037 Uterine Transplantation

 

Revised medical policy effective May 14, 2022

(The following policy was revised to expand medical necessity indications or criteria.)

• SURG.00096 Surgical and Ablative Treatments for Chronic Headaches

 

New medical policies effective August 1, 2022

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

• LAB.00043 Immune Biomarker Tests for Cancer
• LAB.00044 Saliva-based Testing to Determine Drug-Metabolizer Status
• RAD.00067 Quantitative Ultrasound for Tissue Characterization
• TRANS.00038 Thymus Tissue Transplantation

 

New medical policies effective August 13, 2022

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

• LAB.00045 Selected Tests for the Evaluation and Management of Infertility
• SURG.00160 Implanted Port Delivery Systems to Treat Ocular Disease

 

Revised medical policy effective August 13, 2022

(The policy below was 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.00154 Microsurgical Procedures for the Prevention or Treatment of Lymphedema

 

Clinical guideline updates

 

Revised clinical guideline effective March 12, 2022

(The following adopted guideline was revised to expand medical necessity indications or criteria.)

• CG-SURG-86 Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

 

Revised clinical guidelines effective April 1, 2022

(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure code and/or ICD-10-CM diagnosis code updates.)

• CG-DME-06 Compression Devices for Lymphedema
• CG-GENE-10 Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies

 

Archived clinical guidelines effective April 13, 2022

(The following adopted clinical guidelines have been archived and their contents have been transferred to existing Clinical UM Guidelines.)

• CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays [Note: Content moved to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management]
• CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome [Note: Content moved to CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management]
• CG-GENE-09 Genetic Testing for CHARGE Syndrome [Note: Content moved to CG-GENE-13 Genetic Testing for Inherited Diseases]

 

Revised clinical guidelines effective April 13, 2022

(The following adopted guidelines were revised to expand medical necessity indications or criteria.)

• CG-GENE-13 Genetic Testing for Inherited Diseases [Note: Moved content of GENE.00003 Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease and CG-GENE-09 Genetic Testing for CHARGE Syndrome into this document.]
• CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management [Note: Moved content of CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document.]
• CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)

 

Revised clinical guidelines effective April 13, 2022

(The following adopted guidelines were reviewed and may have word changes or clarifications but had no significant changes to the policy position or criteria.)

• CG-GENE-07 BCR-ABL Mutation Analysis
• CG-GENE-16 BRCA Genetic Testing
• CG-GENE-19 Measurable Residual Disease Assessment in Lymphoid Cancers Using Next Generation Sequencing [Note: Content for measurable residual disease testing moved from GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling into this document.]
• CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions
• CG-MED-26 Neonatal Levels of Care
• CG-MED-37 Intensive Programs for Pediatric Feeding Disorders
• CG-MED-68 Therapeutic Apheresis
• CG-MED-88 Preimplantation Genetic Diagnosis Testing
• CG-SURG-09 Temporomandibular Disorders
• CG-SURG-88 Mastectomy for Gynecomastia
• CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
• CG-SURG-97 Cardioverter Defibrillators
• CG-SURG-99 Panniculectomy and Abdominoplasty
• CG-SURG-104 Intraoperative Neurophysiological Monitoring
• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
• CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
• CG-TRANS-02 Kidney Transplantation

 

Unadopted Clinical Guidelines Effective May 1, 2022

(The criteria in the following guidelines will no longer be applied.)

• CG-MED-63 Treatment of Hyperhidrosis
• CG-MED-65 Manipulation Under Anesthesia
• CG-MED-76 Magnetic Source Imaging and Magnetoencephalography
• CG-SURG-05 Maze Procedure
• CG-SURG-28 Transcatheter Uterine Artery Embolization
• CG-SURG-34 Diagnostic Infertility Surgery
• CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
• CG-SURG-75 Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
• CG-SURG-79 Implantable Infusion Pumps
• CG-SURG-86 Endovascular/ Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
• CG-SURG-94 Keratoprosthesis
• CG-SURG-104 Intraoperative Neurophysiological Monitoring
• CG-SURG-105 Corneal Collagen Cross-Linking
• CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
• CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

Revised clinical guideline effective August 1, 2022

(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-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management [Note: Moved content of CG-GENE-01 Janus Kinase 2, CALR, and MPL Gene Mutation Assays and CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome into this document effective April 13, 2022.

 

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