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 Policies Effective 08-29-2019

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

• DRUG.00082 - Daratumumab (DARZALEX®)
• RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

Transitioned Medical Policy Effective 09-01-2019

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

• DRUG.00082 - Daratumumab (DARZALEX®) [Transitioned to ING-CC-0127 Darzalex (daratumumab)]

 

Revised Medical Policy Effective 09-25-2019

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

• GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome

 

Revised Medical Policies Effective 09-25-2019

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

• ADMIN.00006 - Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management (UM) Guideline
• BEH.00002 - Transcranial Magnetic Stimulation
• DME.00011 - Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices
• DME.00012 - Intrapulmonary Percussive Ventilation Devices for Airway Clearance
• GENE.00010 - Panel Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
• GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
• GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
• GENE.00020 - Gene Expression Profile Tests for Multiple Myeloma
• GENE.00024 - DNA-Based Testing for Adolescent Idiopathic Scoliosis
• GENE.00033 - Genetic Testing for Inherited Peripheral Neuropathies
• GENE.00047 - Methylenetetrahydrofolate Reductase Mutation Testing
• 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
• 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
• MED.00103 - Automated Evacuation of Meibomian Gland
• OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
• 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.00062 - Intravascular Optical Coherence Tomography (OCT)
• RAD.00064 - Myocardial Sympathetic Innervation Imaging with or without Single-Photon Emission Computed Tomography (SPECT)
• SURG.00008 - Mechanized Spinal Distraction Therapy
• SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
• SURG.00067 - Percutaneous Vertebroplasty, Kyphoplasty and Sacroplasty
• 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 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.00127 - Sacroiliac Joint Fusion
• SURG.00128 - Implantable Left Atrial Hemodynamic Monitor
• SURG.00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
• SURG.00131 - Lower Esophageal Sphincter Augmentation Devices for the Treatment of Gastroesophageal Reflux Disease (GERD)
• SURG.00135 - Radiofrequency Ablation of the Renal Sympathetic Nerves
• SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• TRANS.00036 - Stem Cell Therapy for Peripheral Vascular Disease

 

Archived Medical Policies Effective 09-28-2019

(The following policies have been archived.)

• MED.00041 - Microvolt T-Wave Alternans
• RAD.00040 - PET Scanning Using Gamma Cameras

 

Revised Medical Policies Effective 10-01-2019

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

• GENE.00001 - Genetic Testing for Cancer Susceptibility
• GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
• GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
• GENE.00028 – Genetic Testing for Colorectal Cancer Susceptibility
• GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases
• LAB.00011 - Analysis of Proteomic Patterns
• SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
• TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and 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.00027 – Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
• TRANS.00028 - Hematopoietic Stem Cell Transplant for Hodgkin Disease and non-Hodgkin Lymphoma
• TRANS.00029 – Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
• TRANS.00030 – Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
• TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
• TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised Medical Policies Effective 11-09-2019

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

• SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

Archived Medical Policy Effective 11-12-2019

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

• GENE.00044 - Analysis of PIK3CA Status in Tumor Cells [Note: Content transferred to CG-GENE-12 PIK3CA Mutation Testing]

 

Archived Medical Policy Effective 11-12-2019

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

• RAD.00004 - Peripheral Bone Mineral Density Measurement [Note: Content transferred to CGMED-39 Bone Mineral Density Testing Measurement

 

Revised Medical Policies Effective 02-01-2020

(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.00023 - Gene Expression Profiling of Melanomas
• GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
• GENE.00046 - Prothrombin (Factor II) Genetic Testing
• MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, Soft Tissue Grafting, and Regenerative Therapy
• SURG.00052 - Percutaneous Vertebral Disc and Vertebral Endplate Procedures
• TRANS.00035 - Non-Hematopoietic Adult Stem Cell Therapy

 

New Medical Policy Effective 02-15-2020

(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.00130 - Surface Electromyography Devices for Seizure Monitoring

 

Revised Medical Policy Effective 02-15-2020

(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.)

• SURG.00011 - Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting

 

Clinical Guideline Updates

 

Revised Clinical Guidelines Effective 09-25-2019

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

• CG-DME-41 - Ultraviolet Light Therapy Delivery Devices for Home Use
• CG-DME-44 - Electric Tumor Treatment Field (TTF)
• CG-GENE-03 - BRAF Mutation Analysis
• CG-MED-63 - Treatment of Hyperhidrosis
• CG-MED-65 - Manipulation Under Anesthesia
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-REHAB-04 - Physical Therapy
• CG-REHAB-05 - Occupational Therapy
• CG-REHAB-06 - Speech-Language Pathology Services
• 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-79 - Implantable Infusion Pumps

 

Revised Clinical Guideline Effective 10-01-2019

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

• CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation)
• CG-SURG-09 - Temporomandibular Disorders
• CG-SURG-86 – Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
• CG-SURG-97 - Cardioverter Defibrillators

 

Revised Clinical Guideline Effective 10-12-2019

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

• CG-MED-68 - Therapeutic Apheresis

 

Revised Clinical Guideline Effective 10-12-2019

(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 Guideline Effective 11-09-2019

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

• CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities

 

Unadopted Clinical Guideline Effective 11-12-2019

(The criteria in the following guideline will no longer be applied to any member claims.)

• CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies

 

Archived Clinical Guideline Effective 11-12-2019

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

• CG-SURG-80 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors [Note: Content transferred to CG-SURG-78 - Locoregional and Surgical Techniques for Treating Primary and Metastatic Liver Malignancies]

 

Adopted Clinical Guideline Effective 11-12-2019

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

• CG-GENE-12 - PIK3CA Mutation Testing [Note: Content moved from GENE.00044 Analysis of PIK3CA Status in Tumor Cells]

 

Revised Clinical Guidelines Effective 02-01-2020

(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-ANC-07 - Inpatient Interfacility Transfers
• CG-GENE-02 - Analysis of RAS Status

 

Revised Clinical Guideline Effective 02-15-2020

(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-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity