Policy Updates Medical Policy & Clinical GuidelinesCommercialJanuary 31, 2020

Medical Policy and Clinical Guideline updates

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

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.

 

Medical Policy Updates

 

Revised Medical Policy Effective 11-12-2019

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

  • BEH.00002 - Transcranial Magnetic Stimulation

 

Revised Medical Policy Effective 11-12-2019

(The following policy was reviewed and had no significant changes to the policy position or criteria.)

  • MED.00124 - Tisagenlecleucel (Kymriah®)

 

Archived Medical Policy Effective 12-14-2019

(The following policy has been archived and has been replaced by AIM guidelines.)

  • RAD.00054 - MRI of the Bone Marrow

 

Revised Medical Policy Effective 12-14-2019

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

  • SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

 

Revised Medical Policies Effective 12-18-2019

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

  • SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  • SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
  • TRANS.00033 - Heart Transplantation

 

Revised Medical Policies Effective 12-18-2019

(The following policies were reviewed and had no significant changes to the policy position or criteria.)

  • ADMIN.00001 - Medical Policy Formation
  • DME.00025 - Self-Operated Spinal Unloading Devices
  • GENE.00016 - Gene Expression Profiling for Colorectal Cancer
  • GENE.00034 - SensiGene® Fetal RhD Genotyping Test
  • GENE.00036 - Genetic Testing for Hereditary Pancreatitis
  • GENE.00037 - Genetic Testing for Macular Degeneration
  • GENE.00039 - Genetic Testing for Frontotemporal Dementia (FTD)
  • GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
  • LAB.00024 - Immune Cell Function Assay
  • LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
  • LAB.00034 - Serological Antibody Testing for Helicobacter Pylori
  • LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
  • MED.00002 - Selected Sleep Testing Services
  • MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
  • MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
  • MED.00065 - Hepatic Activation Therapy
  • MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
  • MED.00091 - Rhinophototherapy
  • MED.00092 - Automated Nerve Conduction Testing
  • MED.00097 - Neural Therapy
  • MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
  • MED.00116 - Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
  • MED.00121 - Implantable Interstitial Glucose Sensors
  • MED.00122 - Wilderness Programs
  • MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
  • MED.00128 - Insulin Potentiation Therapy
  • RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
  • RAD.00036 - MRI of the Breast
  • RAD.00053 - Cervical and Thoracic Discography
  • RAD.00065 - Radiostereometric Analysis (RSA)
  • REHAB.00003 - Hippotherapy
  • SURG.00019 - Transmyocardial Revascularization
  • SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
  • SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
  • SURG.00073 - Epiduroscopy
  • SURG.00079 - Nasal Valve Suspension
  • SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
  • SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
  • SURG.00100 - Cryoablation for Plantar Fasciitis and Plantar Fibroma
  • SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
  • SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
  • SURG.00111 - Axial Lumbar Interbody Fusion
  • SURG.00112 - Occipital Nerve and Supraorbital Nerve Stimulation
  • SURG.00121 - Transcatheter Heart Valve Procedures
  • SURG.00123 - Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
  • SURG.00130 - Annulus Closure After Discectomy
  • SURG.00138 - Laser Treatment of Onychomycosis
  • SURG.00146 - Extracorporeal Carbon Dioxide Removal
  • THER-RAD.00008 - Neutron Beam Radiotherapy
  • THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
  • TRANS.00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
  • TRANS.00008 - Liver Transplantation
  • TRANS.00009 - Lung and Lobar Transplantation
  • TRANS.00010 - Autologous and Allogeneic Pancreatic Islet Cell Transplantation
  • TRANS.00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
  • TRANS.00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
  • TRANS.00026 - Heart/Lung Transplantation
  • TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
  • TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
  • TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
  • TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised Medical Policies Effective 12-31-2019

(The following policies were updated with CPT/HCPCS procedure code updates.)

  • GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
  • GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
  • GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
  • GENE.00023 - Gene Expression Profiling of Melanomas
  • GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing
  • LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
  • LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
  • RAD.00057 - Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
  • SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
  • SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
  • SURG.00150 - Leadless Pacemaker
  • SURG.00153 - Cardiac Contractility Modulation Therapy

 

Revised Medical Policies Effective 01-11-2020

(The following policies were updated with CPT/HCPCS procedure code updates.)

  • MED.00125 - Biofeedback and Neurofeedback
  • RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

Revised Medical Policies Effective 01-11-2020

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

  • ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
  • SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
  • SURG.00127 - Sacroiliac Joint Fusion

 

Revised Medical Policy Effective 01-11-2020

(The following policy was reviewed and had no significant changes to the policy position or criteria.)

  • SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain

 

Revised Medical Policy Effective 02-01-2020

(The following policy was reviewed and had no significant changes to the policy position or criteria.)

  • MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, and Soft Tissue Grafting, and Regenerative Therapy

 

Transitioned Medical Policies Effective 02-05-2020

(The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)

  • MED.00123 - Axicabtagene ciloleucel (Yescarta®) [Transitioned to NG-CC-0151 Yescarta (axicabtagene ciloleucel)]
  • MED.00124 - Tisagenlecleucel (Kymriah®) [Transitioned to ING-CC-0150 Kymriah (tisagenlecleucel)]

 

Revised Medical Policy Effective 02-05-2020

(The following policy was reviewed and had no significant changes to the policy position or criteria.)

  • MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium

 

Archived Medical Policies Effective 02-05-2020

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing [Note: Content transferred to CG-GENE-20 Epidermal Growth Factor Receptor (EGFR) Testing.]
  • GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers [Note: Content transferred to CG-GENE-19 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers.]
  • MED.00109 - Corneal Collagen Cross-Linking [Note: Content transferred to CG-SURG-105 Corneal Collagen Cross-Linking.]
  • RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications [Note: Content transferred to CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications.]
  • SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone [Note: Content transferred to CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.]

 

New Medical Policy Effective 02-05-2020

(The policy below was created and had no significant changes to the policy position or criteria.)

  • GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling [Note: Gene panel codes moved from GENE.00001, GENE.00012, GENE.00025, GENE.00028, GENE.00029, GENE.00030, GENE.00035, and GENE.00043.]


Revised Medical Policies Effective 05-01-2020

(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.)

  • GENE.00025 - Proteogenomic Testing for the Evaluation of Malignancies [Note: Content for molecular profiling and gene panels transferred to GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
  • GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling [Note: Gene panel codes moved from GENE.00001, GENE.00012, GENE.00025, GENE.00028, GENE.00029, GENE.00030, GENE.00035, and GENE.00043.]
  • SURG.00007 - Vagus Nerve Stimulation
  • SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
  • SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
  • SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents

 

Archived Medical Policies Effective 02-05-2020

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • GENE.00001 - Genetic Testing for Cancer Susceptibility [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
  • GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
  • GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility [Note: Content transferred to CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
  • GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome [Note: Content transferred to CG-GENE-16 BRCA Testing for Breast and/or Ovarian Cancer Syndrome. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
  • GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility [Note: Content transferred to CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
  • GENE.00035 - Genetic Testing for TP53 Mutations [Note: Content transferred to CG-GENE-18 Genetic Testing for TP53 Mutations. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
  • GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]

 

Revised Medical Policies Effective 05-16-2020

(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.)

  • SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
  • SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

 

Clinical Guideline Updates

 

Revised Clinical Guideline Effective 12-18-2019

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

  • CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions

 

Revised Clinical Guidelines Effective 12-18-2019

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

  • CG-ANC-04 - Ambulance Services: Air and Water
  • CG-DME-10 - Durable Medical Equipment
  • CG-DME-31 - Wheeled Mobility Devices: Wheelchairs - Powered, Motorized, With or Without Power Seating Systems, and Power Operated Vehicles (POVs)
  • CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs - Ultra Lightweight
  • CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
  • CG-DME-43 - High Frequency Chest Compression Devices for Airway Clearance
  • CG-LAB-13 - Skin Nerve Fiber Density Testing
  • CG-MED-19 - Custodial Care
  • CG-MED-23 - Home Health
  • CG-MED-26 - Neonatal Levels of Care
  • CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
  • CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
  • CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices
  • CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
  • CG-SURG-27 - Gender Reassignment Surgery
  • CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver [Note: Content for radiofrequency ablation to treat tumors outside the liver moved from CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside the Liver]
  • CG-SURG-71 - Reduction Mammoplasty
  • CG-SURG-72 - Endothelial Keratoplasty
  • CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
  • CG-SURG-77 - Refractive Surgery
  • CG-SURG-94 - Keratoprosthesis
  • CG-SURG-95 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention
  • CG-SURG-96 - Intraocular Telescope
  • CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Non-Coronary)

 

Archived Clinical Guideline Effective 12-18-2019

(The following adopted clinical guideline has been archived and its content has been transferred to an existing Clinical UM Guideline.)

  • CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver [Note: Content merged into to CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver]

 

Revised Clinical Guidelines Effective 12-31-2019

(The following adopted clinical guidelines were updated with CPT/HCPCS procedure code updates.)

  • CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
  • CG-MED-77 - SPECT/CT Fusion Imaging
  • CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection

 

Revised Clinical Guideline Effective 01-11-2020

(The following adopted clinical guideline was updated with CPT/HCPCS procedure code updates.)

  • CG-REHAB-11 - Cognitive Rehabilitation

 

Adopted Clinical Guidelines Effective 02-05-2020

(The following guidelines were previously medical policies and have been adopted and have no significant changes.)

  • CG-GENE-13 - Genetic Testing for Inherited Diseases [Note: Content moved from GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent and GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases.]
  • CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management [Note: Content moved from GENE.00001 Genetic Testing for Cancer Susceptibility.]
  • CG-GENE-15 - Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis [Note: Content moved from GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility.]
  • CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome [Note: Content moved from GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome.]
  • CG-GENE-17 - RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility [Note: Content moved from GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility.]
  • CG-GENE-18 - Genetic Testing for TP53 Mutations [Note: Content moved from GENE.00035 Genetic Testing for TP53 Mutations.]
  • CG-GENE-19 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers [Note: Content for genotype testing for single polymorphisms of metabolizing enzymes for specific drugs moved from GENE.00045 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers.]
  • CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing [Note: Content moved from GENE.00006 Epidermal Growth Factor Receptor (EGFR) Testing.]
  • CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications [Note: Content moved from RAD.00023 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications.]
  • CG-SURG-105 - Corneal Collagen Cross-Linking [Note: Content moved from MED.00109 Corneal Collagen Cross-Linking.]
  • CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone [Note: Content moved from SURG.00122 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.]

 

Revised Clinical Guideline Effective 05-01-2020

(The following adopted guideline were revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-GENE-13 - Genetic Testing for Inherited Diseases [Note: Content moved from GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent and GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases.]
  • CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management [Note: Content moved from GENE.00001 Genetic Testing for Cancer Susceptibility.]
  • CG-MED-68 - Therapeutic Apheresis

PUBLICATIONS: February 2020 Empire Provider News