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. Empire’s Medical Policies and Clinical Guidelines can be found at https://empireblue.com.

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. 

Medical Policy updates

Archived Medical Policy effective October 1, 2023

The following policy has been archived:

• GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy) Content moved to GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling

New Medical Policy effective October 1, 2023

The following policy is new:

• SURG.00161 Nanoparticle-Mediated Thermal Ablation

Revised Medical Policies effective October 1, 2023

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

• DME.00011 Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling Moved content of GENE.00049 Circulating Tumor DNA Panel Testing (Liquid Biopsy) to this document.
• MED.00004 Noninvasive Imaging Technologies for the Evaluation of Skin Lesions
• SURG.00121 Transcatheter Heart Valve Procedures
• SURG.00150 Leadless Pacemaker

Clinical Guideline updates

Revised Clinical Guidelines effective October 1, 2023

The following adopted guidelines were revised and might result in services that were previously covered but may now be found to be not medically necessary:

• CG-DME-31 Powered Wheeled Mobility Devices
• CG-MED-73 Hyperbaric Oxygen Therapy (Systemic/Topical)
• CG-SURG-95 Nerve Stimulation and Percutaneous or Implantable Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention