Medical Policy 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

 

New Medical Policies Effective 09-01-2020

(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.00041 - Low Intensity Therapeutic Ultrasound for the Treatment of Pain
• GENE.00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
• GENE.00054 - Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
• SURG.00154 - Microsurgical Procedures for the Treatment of Lymphedema
• SURG.00155 - Cryoneurolysis for Treatment of Peripheral Nerve Pain

Revised Medical Policies Effective 09-01-2020

(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.)

• DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices
• SURG.00032 - Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
• SURG.00150 - Leadless Pacemaker
  
  

Revised Medical Policies Effective 09-19-2020

(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.)

• RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
• SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches

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