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

 

Revised Medical Policies Effective 11-12-2020

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

• GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
• MED.00129 - Gene Therapy for Spinal Muscular Atrophy

 

Revised Medical Policy Effective 11-12-2020

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

• ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin

 

Archived Medical Policy Effective 12-16-2020

(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)

• GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing [Note: Content transferred to CG-GENE-21 Cell-Free Fetal DNA-Based Prenatal Testing]

 

Revised Medical Policy Effective 12-16-2020

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

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

Revised Medical Policies Effective 12-16-2020

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

• ADMIN.00001 - Medical Policy Formation
• GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
• GENE.00016 - Gene Expression Profiling for Colorectal Cancer
• GENE.00025 - Proteogenomic Testing for the Evaluation of Malignancies
• GENE.00036 - Genetic Testing for Hereditary Pancreatitis
• GENE.00037 - Genetic Testing for Macular Degeneration
• GENE.00039 - Genetic Testing for Frontotemporal Dementia (FTD)
• GENE.00049 - Circulating Tumor DNA Testing for Cancer (Liquid Biopsy)
• LAB.00024 - Immune Cell Function Assay
• LAB.00026 - Systems Pathology Testing for Predicting Risk of Prostate Cancer Progression and Recurrence
• LAB.00034 - Serological Antibody Testing for Helicobacter Pylori
• MED.00002 - Selected Sleep Testing Services
• MED.00065 - Hepatic Activation Therapy
• MED.00091 - Rhinophototherapy
• MED.00092 - Automated Nerve Conduction Testing
• MED.00097 - Neural Therapy
• MED.00115 - Outpatient Cardiac Hemodynamic Monitoring Using a Wireless Sensor for Heart Failure Management
• MED.00116 - Near-Infrared Spectroscopy Brain Screening for Hematoma Detection
• MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
• MED.00121 - Implantable Interstitial Glucose Sensors
• MED.00122 - Wilderness Programs
• MED.00126 - Fractional Exhaled Nitric Oxide and Exhaled Breath Condensate Measurements for Respiratory Disorders
• MED.00128 - Insulin Potentiation Therapy
• MED.00130 - Surface Electromyography Devices for Seizure Monitoring
• RAD.00036 - MRI of the Breast
• RAD.00053 - Cervical and Thoracic Discography
• RAD.00065 - Radiostereometric Analysis
• REHAB.00003 - Hippotherapy
• SURG.00019 - Transmyocardial Revascularization
• SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
• SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
• SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
• SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
• SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
• SURG.00073 - Epiduroscopy
• SURG.00079 - Nasal Valve Suspension
• SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
• SURG.00098 - Mechanical Embolectomy for Treatment of Acute Stroke
• SURG.00099 - Convection Enhanced Delivery of Therapeutic Agents to the Brain
• SURG.00100 - Cryoablation for Plantar Fasciitis and Plantar Fibroma
• SURG.00102 - Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence
• SURG.00123 - Transmyocardial/ Perventricular Device Closure of a Ventricular Septal Defect
• SURG.00130 - Annulus Closure After Discectomy
• SURG.00138 - Laser Treatment of Onychomycosis
• SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• SURG.00146 - Extracorporeal Carbon Dioxide Removal
• THER-RAD.00008 - Neutron Beam Radiotherapy
• TRANS.00008 - Liver Transplantation
• TRANS.00009 - Lung and Lobar Transplantation
• TRANS.00010 - Autologous and Allogeneic Pancreatic Islet Cell 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.00026 - Heart/Lung Transplantation
• TRANS.00027 - Hematopoietic Stem Cell Transplantation for Pediatric Solid Tumors
• TRANS.00029 - Hematopoietic Stem Cell Transplantation for Genetic Diseases and Aplastic Anemias
• TRANS.00030 - Hematopoietic Stem Cell Transplantation for Germ Cell Tumors
• TRANS.00033 - Heart Transplantation
• TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus

 

Revised Medical Policies Effective 12-16-2020

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

• GENE.00023 - Gene Expression Profiling of Melanomas
• GENE.00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
• MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
• MED.00120 - Gene Therapy for Ocular Conditions
• SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
• SURG.00151 - Balloon Dilation of the Eustachian Tubes
• TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

New Medical Policies Effective 04-01-2021

(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.)

• GENE.00055 - Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
• SURG.00158 - Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain [Note: Content addressing implantable devices (temporarily or permanently implanted) moved from DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices]

Revised Medical Policy Effective 04-01-2021

(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.)

• DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices [Note: Content addressing implantable devices (temporarily or permanently implanted) moved to SURG.00158 - Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain]

New Medical Policy Effective 04-03-2021

(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.)

• LAB.00037 - Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)

 

Revised Medical Policy Effective 04-17-2021

(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.)

• SURG.00062 - Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele

 

Clinical Guideline Updates

 

Revised Clinical Guidelines Effective 11-12-2020

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

• CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
• CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome
• CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

Revised Clinical Guideline Effective 11-12-2020

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

• CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults

 

Revised Clinical Guidelines Effective 12-16-2020

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

• CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
• CG-GENE-18 - Genetic Testing for TP53 Mutations
• CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing

 

Revised Clinical Guidelines Effective 12-16-2020

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

• CG-ANC-04 - Ambulance Services: Air and Water
• CG-ANC-07 - Inpatient Interfacility Transfers
• CG-BEH-14 - Intensive In-Home Behavioral Health Services
• CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-DME-31 - Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
• CG-DME-33 - Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight
• CG-DME-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
• CG-DME-43 - High Frequency Chest Compression Devices for Airway Clearance
• CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
• CG-GENE-15 - Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis
• CG-GENE-17 - RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
• CG-GENE-19 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
• CG-LAB-13 - Skin Nerve Fiber Density Testing
• CG-MED-19 - Custodial Care
• CG-MED-23 - Home Health
• CG-MED-26 - Neonatal Levels of Care
• CG-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
• CG-MED-79 - Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
• CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices
• CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
• CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
• CG-SURG-77 - Refractive Surgery
• CG-SURG-92 - Paraesophageal Hernia Repair
• CG-SURG-94 - Keratoprosthesis
• CG-SURG-96 - Intraocular Telescope
• CG-SURG-105 - Corneal Collagen Cross-Linking
• CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone

 

Revised Clinical Guidelines Effective 12-16-2020

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

• CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
• CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
• CG-GENE-13 - Genetic Testing for Inherited Diseases
• CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
• CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring

 

Revised Clinical Guideline Effective 01-16-2021

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

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

 

Revised Clinical Guidelines Effective 04-17-2021

(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-SURG-71 - Reduction Mammoplasty
• CG-SURG-72 - Endothelial Keratoplasty
• CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
• CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Noncoronary)

 

935-0121-PN-NY