Medical policy and clinical guideline updates

Material adverse change (MAC) notification

 

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.

 

To view medical policies and utilization management guidelines applicable to members enrolled in the Blue Cross and Blue Shield Service Benefit Plan (commonly referred to as the Federal Employee Program® (FEP®)), please visit www.fepblue.org > Policies & Guidelines.

 

Medical Policy Updates

 

Revised Medical Policy Effective 08-19-2021

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

• 00121 - Transcatheter Heart Valve Procedures

 

Revised Medical Policies Effective 09-18-2021

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

• 00032 - Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
• 00077 - Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
• 00119 - Endobronchial Valve Devices

 

Revised Medical Policies Effective 10-01-2021

(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)

• 00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• 00011 Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
• 00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
• 00023 - Hematopoietic Stem Cell Transplantation for Multiple Myeloma and Other Plasma Cell Dyscrasias
• 00024 - Hematopoietic Stem Cell Transplantation for Select Leukemias and Myelodysplastic Syndrome
• 00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
• 00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
• 00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
• 00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
• 00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
• 00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
• 00035 - Other Stem Cell Therapy

 

Revised Medical Policies Effective 10-06-2021

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

• 00006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
• 00025 - Self-Operated Spinal Unloading Devices
• 00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
• 00020 - Gene Expression Profile Tests for Multiple Myeloma
• 00023 - Gene Expression Profiling of Melanomas
• 00033 - Genetic Testing for Inherited Peripheral Neuropathies
• 00034 - SensiGene® Fetal RhD Genotyping Test
• 00047 - Methylenetetrahydrofolate Reductase Mutation Testing
• 00011 - Analysis of Proteomic Patterns
• 00019 - Proprietary Algorithms for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
• 00028 - Serum Biomarker Tests for Multiple Sclerosis
• 00029 - Rupture of Membranes Testing in Pregnancy
• 00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
• 00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
• 00055 - Wearable Cardioverter Defibrillators
• 00082 - Quantitative Sensory Testing
• 00089 - Quantitative Muscle Testing Devices
• 00095 - Anterior Segment Optical Coherence Tomography
• 00096 - Low-Frequency Ultrasound Therapy for Wound Management
• 00099 - Electromagnetic Navigational Bronchoscopy
• 00103 - Automated Evacuation of Meibomian Gland
• 00134 - Noninvasive Heart Failure and Arrhythmia Monitoring System
• 00057 - Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
• 00061 - PET/MRI
• 00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
• 00008 Mechanized Spinal Distraction Therapy
• 00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• 00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
• 00088 - Coblation® Therapies for Musculoskeletal Conditions
• 00092 - Implanted Devices for Spinal Stenosis
• 00101 - Suprachoroidal Injection of a Pharmacologic Agent
• 00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
• 00107 - Prostate Saturation Biopsy
• 00114 - Facet Joint Allograft Implants for Facet Disease
• 00128 - Implantable Left Atrial Hemodynamic Monitor
• 00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
• 00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
• 00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
• 00153 - Cardiac Contractility Modulation Therapy
• 00156 - Implanted Artificial Iris Devices
• 00157 - Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis
• 00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)

 

Archived Medical Policy Effective 10-06-2021

(The following policy has been archived.)

• MED.00085 - Antineoplaston Therapy

 

Archived Medical Policies Effective 10-09-2021

(The following policies have been archived.)

• 00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
• 00037 - Whole Body Computed Tomography Scanning

 

Revised Medical Policies Effective 10-16-2021

(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)

• 00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
• 00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

 

New Medical Policies Effective 01-01-2022

(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.)

• 00043 - Neuromuscular Electrical Training for the Treatment of Obstructive Sleep Apnea or Snoring
• 00058 - TruGraf Blood Gene Expression Test for Transplant Monitoring
• 00040 - Serum Biomarker Tests for Risk of Preeclampsia
• 00042 - Molecular Signature Test for Predicting Response to Tumor Necrosis Factor Inhibitor Therapy for Rheumatoid Arthritis

 

Revised Medical Policy Effective 01-01-2022

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

• 00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays

 

New Medical Policy Effective 01-15-2022

(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.)

• OR-PR.00007 - Microprocessor Controlled Knee-Ankle-Foot Orthosis

 

Clinical Guideline Updates

 

Revised Clinical Guidelines Effective 08-19-2021

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

• CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment
• CG-MED-55 - Site of Care: Advanced Radiologic Imaging
• CG-SURG-82 - Bone-Anchored and Bone Conduction Hearing Aids

 

Revised Clinical Guidelines Effective 10-06-2021

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

• CG-DME-10 - Durable Medical Equipment
• CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use
• CG-MED-63 - Treatment of Hyperhidrosis
• CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins
• CG-MED-65 - Manipulation Under Anesthesia
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-MED-69 - Inhaled Nitric Oxide
• CG-MED-83 - Site of Care: Specialty Pharmaceuticals
• CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 - Private Duty Nursing in the Home Setting
• CG-SURG-28 - Transcatheter Uterine Artery Embolization
• CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
• CG-SURG-52 - Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services
• CG-SURG-55 - Cardiac Electrophysiological Studies (EPS) and Catheter Ablation
• CG-SURG-79 - Implantable Infusion Pumps
• CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity

 

Revised Clinical Guideline Effective 10-16-2021

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

• CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

 

Revised Clinical Guidelines Effective 10-16-2021

(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)

• CG-MED-68 - Therapeutic Apheresis
• CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence, Urinary Retention

 

Revised Clinical Guideline Effective 01-01-2022

(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-DME-44 - Electric Tumor Treatment Field (TTF)

 

Revised Clinical Guideline Effective 01-15-2022

(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-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure

 

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