Medical Policy & 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 Policy Effective 09-01-2020

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

• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling

 

Revised Medical Policy Effective 09-01-2020

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

• GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies

 

Revised Medical Policies Effective 10-01-2020

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

• GENE.00037 - Genetic Testing for Macular Degeneration
• OR-PR.00005 - Upper Extremity Myoelectric Orthoses
• OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
• SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
• SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
• SURG.00127 - Sacroiliac Joint Fusion
• SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
• TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
• TRANS.00035 - Other Stem Cell Therapy
•  
• Revised Medical Policies Effective 10-01-2020
• (The following policies were reviewed and had no significant changes to the policy position or criteria.)
• SURG.00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
• SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
•  
• Revised Medical Policies Effective 10-07-2020
• (The following policies were reviewed and had no significant changes to the policy position or criteria.)
• ADMIN.00001 - Medical Policy Formation
• ADMIN.00006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
• DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
• DME.00025 - Self-Operated Spinal Unloading Devices
• GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
• GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
• GENE.00023 - Gene Expression Profiling of Melanomas
• GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
• GENE.00034 - SensiGene® Fetal RhD Genotyping Test
• GENE.00046 - Prothrombin (Factor II) Genetic Testing
• GENE.00047 - Methylenetetra-hydrofolate Reductase Mutation Testing
• LAB.00011 - Analysis of Proteomic Patterns
• LAB.00019 - Serum Markers for Liver Fibrosis in the Evaluation and Monitoring of Chronic Liver Disease
• LAB.00028 - Serum Biomarker Tests for Multiple Sclerosis
• LAB.00029 - Rupture of Membranes Testing in Pregnancy
• LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
• LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
• MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
• MED.00055 - Wearable Cardioverter Defibrillators
• MED.00082 - Quantitative Sensory Testing
• MED.00085 - Antineoplaston Therapy
• MED.00089 - Quantitative Muscle Testing Devices
• MED.00095 - Anterior Segment Optical Coherence Tomography
• MED.00096 - Low-Frequency Ultrasound Therapy for Wound Management
• MED.00099 - Electromagnetic Navigational Bronchoscopy
• OR-PR.00003 - Microprocessor Controlled Lower Limb Prostheses
• RAD.00037 - Whole Body Computed Tomography Scanning
• RAD.00057 - Near-Infrared Coronary Imaging  and Near-Infrared Intravascular Ultrasound Coronary Imaging
• RAD.00061 - PET/MRI
• RAD.00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
• SURG.00008 - Mechanized Spinal Distraction Therapy
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• SURG.00082 - Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures of the Appendicular System
• SURG.00088 - Coblation® Therapies for Musculoskeletal Conditions
• SURG.00092 - Implanted Devices for Spinal Stenosis
• SURG.00095 - Viscocanalostomy and Canaloplasty
• SURG.00101 - Suprachoroidal Injection of a Pharmacologic Agent
• SURG.00104 - Extraosseous Subtalar Joint Implantation and Subtalar Arthroereisis
• SURG.00114 - Facet Joint Allograft Implants for Facet Disease
• SURG.00119 - Endobronchial Valve Devices
• SURG.00128 - Implantable Left Atrial Hemodynamic Monitor
• SURG.00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
• SURG.00153 - Cardiac Contractility Modulation Therapy
• TRANS.00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)

 

Archived Medical Policy Effective 10-07-2020

(The following policy has been archived)

• RAD.00062 - Intravascular Optical Coherence Tomography (OCT)

 

Revised Medical Policy Effective 01-01-2021

(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.)

• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling

 

New Medical Policies Effective 01-16-2021

(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.00134 - Non-invasive Heart Failure and Arrhythmia Management and Monitoring System
• SURG.00156 - Implanted Artificial Iris Devices
• SURG.00157 - Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis

 

Revised Medical Policies Effective 01-16-2021

(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.)

• MED.00103 - Automated Evacuation of Meibomian Gland
• SURG.00077 - Uterine Fibroid Ablation: Laparoscopic, Percutaneous or Transcervical Image Guided Techniques
• SURG.00112 - Implantation of Occipital, Supraorbital or Trigeminal Nerve Stimulation Devices
• SURG.00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring

 

Clinical Guideline Updates

 

Revised Clinical Guidelines Effective 08-20-2020

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

• CG-GENE-03 - BRAF Mutation Analysis
• CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity

 

Revised Clinical Guidelines Effective 08-20-2020

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

• CG-MED-55 - Site of Care: Advanced Radiologic Imaging
• CG-MED-83 - Site of Care: Specialty Pharmaceuticals

 

Revised Clinical Guidelines Effective 10-01-2020

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

• CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability (Intellectual Developmental Disorder) and Congenital Anomalies
• CG-MED-68 - Therapeutic Apheresis
• CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
• CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
• CG-SURG-09 - Temporomandibular Disorders
• CG-SURG-72 - Endothelial Keratoplasty
• CG-SURG-92 - Paraesophageal Hernia Repair
• CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention

 

Revised Clinical Guideline Effective 10-01-2020

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

• CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use

 

Revised Clinical Guidelines Effective 10-07-2020

(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-44 - Electric Tumor Treatment Field (TTF)
• CG-MED-63 - Treatment of Hyperhidrosis
• CG-MED-65 - Manipulation Under Anesthesia
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-MED-69 - Inhaled Nitric Oxide
• CG-REHAB-07 - Skilled Nursing and Skilled Rehabilitation Services (Outpatient)
• CG-REHAB-08 - Private Duty Nursing in the Home Setting
• CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
• CG-SURG-63 - Cardiac Resynchronization Therapy with or without an Implantable Cardioverter Defibrillator for the Treatment of Heart Failure
• CG-SURG-79 - Implantable Infusion Pumps

 

Unadopted Clinical Guideline Effective 11-01-2020

(The following adopted guideline has been unadopted and has been replaced by AIM guidelines.)

• CG-SURG-74 - Total Ankle Replacement

 

Adopted Clinical Guideline Effective 01-01-2021

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

• CG-SURG-104 - Intraoperative Neurophysiological Monitoring

 

Revised Clinical Guideline Effective 01-16-2021

(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-28 - Transcatheter Uterine Artery Embolization

 

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 January 16, 2021, 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-MED-63 - Treatment of Hyperhidrosis

 

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