Medical Policy and Clinical Guideline updates

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 Policies Effective 02-27-2020

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

• GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
• SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)

 

Revised Medical Policy Effective 04-01-2020

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

• GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing
  
  

Revised Medical Policies Effective 04-15-2020

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

• ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
• DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting
• DME.00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
• DME.00032 - Automated External Defibrillators for Home Use
• GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
• GENE.00007 - Cardiac Ion Channel Genetic Testing
• GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
• GENE.00017 - Genetic Testing for Diagnosis of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
• GENE.00038 - Genetic Testing for Statin-Induced Myopathy
• GENE.00050 - Gene Expression Profiling for Coronary Artery Disease
• LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
• LAB.00011 - Analysis of Proteomic Patterns
• LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
• LAB.00025 - Topographic Genotyping
• MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
• 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.00077 - In-Vivo Analysis of Gastrointestinal Lesions
• MED.00087 - Imaging Techniques 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 Endproducts (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
• OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
• RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification
• RAD.00044 - Magnetic Resonance Neurography
• RAD.00052 - Positional MRI
• RAD.00059 - Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
• SURG.00022 - Lung Volume Reduction Surgery
• SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
• 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.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
• 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.00107 - Prostate Saturation Biopsy
• 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.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
• SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
• SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
• SURG.00151 - Balloon Dilation of Eustachian Tubes
• SURG.00152 - Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
• 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.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
• TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
• TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

Revised Medical Policies Effective 04-01-2020

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

• GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
  
  

Archived Medical Policy Effective 04-15-2020

(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)

• SURG.00016 - Stereotactic Radiofrequency Pallidotomy [Note: Content transferred to CG-SURG-108 Stereotactic Radiofrequency Pallidotomy.]
  
  

Archived Medical Policies Effective 04-15-2020

(The following policies have been archived.)

• MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
• RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
• THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
  
  

Archived Medical Policy Effective 04-18-2020

(The following policy has been archived.)

• MED.00007 - Prolotherapy for Joint and Ligamentous Conditions

 

Revised Medical Policy Effective 04-18-2020

(The following policy was updated with CPT/HCPCS procedure code updates.)

• SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

 

Revised Medical Policy Effective 04-18-2020

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

• SURG.00127 - Sacroiliac Joint Fusion

 

Archived Medical Policy Effective 05-17-2020

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

• SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty

 

Archived Medical Policy Effective 07-01-2020

(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)

• SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) [Note: Content transferred to CG-SURG-107 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH).]

 

Clinical Guideline Updates

 

Revised Clinical Guidelines Effective 02-27-2020

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

• CG-REHAB-04 - Rehabilitative and Habilitative Services: Medicine/Physical Therapy
• CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
• CG-REHAB-06 - Rehabilitative and Habilitative Services: Speech-Language Pathology

 

Revised Clinical Guidelines Effective 04-01-2020

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

• CG-MED-23 – Home Health
• CG-REHAB-04 - Rehabilitative and Habilitative Services: Medicine/Physical Therapy
• CG-REHAB-05 - Rehabilitative and Habilitative Services: Occupational Therapy
• CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
• CG-SURG-27 - Gender Reassignment Surgery

 

Revised Clinical Guidelines Effective 04-15-2020

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

• CG-DME-06 - Pneumatic Compression Devices for Lymphedema
• CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
• CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
• CG-GENE-07 - BCR-ABL Mutation Analysis
• CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
• CG-GENE-09 - Genetic Testing for CHARGE Syndrome
• CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
• CG-MED-55 - Level of Care: Advanced Radiologic Imaging
• CG-MED-69 - Inhaled Nitric Oxide
• CG-SURG-09 - Temporomandibular Disorders
• CG-SURG-74 - Total Ankle Replacement
• CG-SURG-97 - Cardioverter Defibrillators
• CG-SURG-99 - Panniculectomy and Abdominoplasty
• CG-TRANS-02 - Kidney Transplantation

 

Recategorized Clinical Guideline Effective 04-15-2020

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

• CG-MED-88 Preimplantation Genetic Diagnosis Testing [NOTE: This guideline has been renumbered, formerly CG-GENE-06.]

 

Archived Clinical Guideline Effective 04-15-2020

(The following adopted clinical guideline has been archived.)

• CG-MED-82 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting

 

Archived Clinical Guideline Number Effective 04-15-2020

(The following guideline number has been archived and its content has been transferred to a new Clinical UM Guideline number.)

• CG-GENE-06 - Preimplantation Genetic Diagnosis Testing [Note: Content transferred to CG-MED-88 Preimplantation Genetic Diagnosis Testing.]

 

Revised Clinical Guideline Effective 05-01-2020

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

• CG-GENE-13 - Genetic Testing for Inherited Diseases

 

Adopted Clinical Guideline Effective 07-01-2020

(The following guideline was previously a medical policy and has been adopted and has no significant changes.)

• CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) [Note: Content moved from SURG.00028 Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH).]

 

Corrections to the Policy Update section of the April 2020 Newsletter

In the April 2020 provider newsletter we communicated that a coding update would be made in the claims system effective July 18, 2020 which may result in a not medically necessary determination for CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone. This change will not be put in place on July 18, 2020, and we will communicate, in the future, when the coding update will be applied.

 

420-0520-PN-NY