Medical Policy and Clinical Guideline updates

These updates list the new and/or revised Medical Policies and Clinical Guidelines for Empire BlueCross BlueShield (Empire). The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guideline 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 service is 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. To view Medical Policies and Clinical Guidelines for Empire, go to empireblue.com > select Providers > under Provider Resources > select Policies, Guidelines & Manuals.

Note: These updates may not apply to all administrative services only accounts as some accounts may have nonstandard benefits that apply.

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program [FEP^®]), visit fepblue.org > Policies & Guidelines.

Clinical Guideline updates

Adopted Clinical Guideline effective March 16, 2024

The following guideline will be applied and might result in services that were previously covered but may now be found to be not medically necessary:

• CG-MED-95 Transanal Irrigation

Revised Clinical Guideline effective March 16, 2024

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-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis

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