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 06-13-2020
(The following policies were revised to expand medical necessity indications or criteria.)

• DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting

• DME.00034 - Standing Frames
• SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis

Revised Medical Policies Effective 07-01-2020

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

• GENE.00010 - Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
• MED.00129 - Gene Therapy for Spinal Muscular Atrophy
• SURG.00010 - Treatments for Urinary Incontinence
• SURG.00126 - Irreversible Electroporation

Revised Medical Policies Effective 07-01-2020

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

• GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
• LAB.00011 - Analysis of Proteomic Patterns
• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

Archived Medical Policy Effective 07-08-2020

(The following policy has been archived and its content has been transferred to an existing Medical Policy.)

• TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease [Note: Content transferred to TRANS.00035 Other Stem Cell Therapy]

Revised Medical Policy Effective 07-08-2020

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

• MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

Revised Medical Policies Effective 07-08-2020

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

• ADMIN.00002 - Preventive Health Guidelines
• ADMIN.00004 - Medical Necessity Criteria
• ADMIN.00005 - Investigational Criteria
• ADMIN.00007 - Immunizations
• ANC.00006 - Biomagnetic Therapy
• DME.00024 – Transtympanic Micropressure for Treatment of Ménière’s Disease
• DME.00030 – Altered Auditory Feedback Devices for the Treatment of Stuttering
• DME.00037 – Cooling Devices and Combined Cooling/Heating Devices
• DME.00038 – Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
• DME.00039 – Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
• GENE.00041 – Genetic Testing to Confirm the Identity of Laboratory Specimens
• GENE.00051 – Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
• LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
• LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
• LAB.00031 - Advanced Lipoprotein Testing
• LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer
• LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
• MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)
• MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
• MED.00098 - Hyperoxemic Reperfusion Therapy
• MED.00127 - Chelation Therapy
• OR-PR.00005 - Upper Extremity Myoelectric Orthoses
• OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
• RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/Videofluoroscopy)
• RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
• SURG.00005 - Partial Left Ventriculectomy
• SURG.00045 - Extracorporeal Shock Wave Therapy
• SURG.00071 - Percutaneous and Endoscopic Spinal Surgery
• SURG.00076 - Nerve Graft after Prostatectomy
• SURG.00077 - Uterine Fibroid Ablation: Laparoscopic or Percutaneous Image Guided Techniques
• SURG.00084 - Implantable Middle Ear Hearing Aids
• SURG.00105 - Bicompartmental Knee Arthroplasty
• SURG.00111 - Axial Lumbar Interbody Fusion
• SURG.00116 - High Resolution Anoscopy Screening for Anal Intrathelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
• SURG.00118 - Bronchial Thermoplasty
• SURG.00120 - Internal Rib Fixation Systems
• SURG.00121 - Transcatheter Heart Valve Procedures
• SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
• SURG.00134 - Interspinous Process Fixation Devices
• SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
• SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
• SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
• TRANS.00035 - Other Stem Cell Therapy [Note: Content of TRANS.00036 Stem Cell Therapy for Peripheral Vascular Disease has been moved to this Medical Policy.]
  
  

New Medical Policy Effective 10-01-2020

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

• MED.00133 - Ingestion Event Monitors

Revised Medical Policies Effective 10-01-2020

(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.00007 - Cardiac Ion Channel Genetic Testing
• GENE.00017 - Genetic Testing for Diagnosis of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
• GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome
• GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• SURG.00007 – Vagus Nerve Stimulation

New Medical Policies Effective 10-03-2020

(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.)

• DME.00042 - Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
• MED.00131 – Electronic Home Visual Field Monitoring

Revised Medical Policies Effective 10-03-2020

(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.)

• DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• MED.00004 - Technologies for the Evaluation of Skin Lesions (Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

Revised Medical Policies Effective 10-17-2020

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

• ANC.00007 - Cosmetic and Reconstructive Services: Skin Related [Note: Moved information addressing dermal fillers, collagen injections and hyaluronic acid gel products to new policy MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures]
• MED.00110 - Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications [Note: Moved information addressing autologous adipose-derived regenerative cell therapy to new policy MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures]
• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting [Note: Moved HCPCS codes C1878 and L8607 for soft tissue fillers to new policy MED.00132 Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures]

New Medical Policies Effective 10-17-2020

(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.)

• MED.00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures [Note: Content related to dermal fillers, collagen injections and hyaluronic acid gel products moved from ANC.00007 Cosmetic and Reconstructive Services: Skin Related; content for autologous adipose-derived regenerative cell therapy (for example, Lipogems) moved from MED.00110; and HCPCS codes C1878 and L8607 for soft tissue fillers moved from SURG.00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting]
• THER-RAD.00012 - Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation

Clinical Guideline Updates

Revised Clinical Guidelines Effective 06-13-2020

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

• CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry
• CG-MED-77 - SPECT/CT Fusion Imaging

 

Revised Clinical Guideline Effective 07-01-2020

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

• CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome

 

Revised Clinical Guideline Effective 07-01-2020

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

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

 

Revised Clinical Guidelines Effective 07-08-2020

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

• CG-DME-45 - Ultrasound Bone Growth Stimulation
• CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
• CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
• CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults
• CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome
• CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
• CG-MED-83 - Level of Care: Specialty Pharmaceuticals
• CG-REHAB-11 - Cognitive Rehabilitation
• CG-SURG-05 - Maze Procedure
• CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
• CG-SURG-12 - Penile Prosthesis Implantation
• CG-SURG-34 - Diagnostic Infertility Surgery
• CG-SURG-35 - Intracytoplasmic Sperm Injection (ICSI)
• CG-SURG-50 - Assistant Surgeons
• CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
• CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
• CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids
• CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery
• CG-SURG-85 - Hip Resurfacing
• CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
• CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
• CG-SURG-88 - Mastectomy for Gynecomastia
• CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
• CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus
• CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Revised Clinical Guidelines Effective 10-01-2020

(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-GENE-02 - Analysis of RAS Status
• CG-GENE-13 - Genetic Testing for Inherited Diseases
• CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
• CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation (Radiofrequency and Cryoablation)

 

Revised Clinical Guidelines Effective 10-17-2020

(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-46 - Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
• CG-MED-68 - Therapeutic Apheresis
• CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Coding Updates

 

As a result of coding updates in the claims system, the claim system edits for the clinical guideline listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary determination.

 

Effective October 17, 2020, we will be implementing coding updates in the claims system for the following clinical guideline listed below which may result in not medically necessary determinations for certain services.

• CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

 

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