Policy Updates Medical Policy & Clinical GuidelinesCommercialMarch 31, 2021

Medical policy updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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 Policies Effective 02-18-2021

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

  • SURG.00121 - Transcatheter Heart Valve Procedures
  • SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)

 

New Medical Policy Effective 04-01-2021

(The policy below is new.)

  • GENE.00056 - Gene Expression Profiling for Bladder Cancer [Note: CPT codes 0012M and 0013M moved from LAB.00011 Analysis of Proteomic Patterns

 

Revised Medical Policies Effective 04-01-2021

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

  • OR-PR.00003 – Microprocessor Controlled Lower Limb Prosthesis
  • OR-PR.00005 - Upper Extremity Myoelectric Orthoses
  • SURG.00007 – Vigus Nerve Stimulation

 

Revised Medical Policies Effective 04-01-2021

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

  • GENE.00049 - Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy) [Note: Moved CPT code 0229U to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
  • GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
  • LAB.00011 - Analysis of Proteomic Patterns [Note: Moved CPT codes 0012M and 0013M to GENE.00056 Gene Expression Profiling for Bladder Cancer].SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency

 

Revised Medical Policy Effective 04-07-2021

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

  • MED.00087 - Optical Detection for Screening and Identification of Cervical Cancer

 

Revised Medical Policies Effective 04-07-2021

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

  • ANC.00007 - Cosmetic and Reconstructive Services: Skin Related
  • ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
  • DME.00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
  • DME.00032 - Automated External Defibrillators for Home Use
  • DME.00041 - Low Intensity Therapeutic Ultrasound
  • GENE.00009 - Gene Expression Profiling and Genomic Biomarker Tests for Prostate Cancer
  • GENE.00038 - Genetic Testing for Statin-Induced Myopathy
  • GENE.00050 - Gene Expression Profiling for Coronary Artery Disease
  • GENE.00054 - Paired DNA and Messenger RNA (mRNA) Genetic Testing to Detect, Diagnose and Manage Cancer
  • LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
  • LAB.00015 - Detection of Circulating Tumor Cells
  • LAB.00025 - Topographic Genotyping
  • MED.00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
  • MED.00024 - Adoptive Immunotherapy and Cellular Therapy
  • MED.00053 - Non-Invasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
  • MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
  • MED.00059 - Idiopathic Environmental Illness (IEI)
  • MED.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
  • MED.00102 - Ultrafiltration in Decompensated Heart Failure
  • MED.00104 - Non-Invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
  • MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
  • MED.00111 - Intracardiac Ischemia Monitoring
  • MED.00112 - Autonomic Testing
  • MED.00118 - Continuous Monitoring of Intraocular Pressure
  • MED.00120 - Gene Therapy for Ocular Conditions
  • MED.00125 - Biofeedback and Neurofeedback
  • MED.00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
  • OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
  • RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification
  • RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
  • RAD.00044 - Magnetic Resonance Neurography
  • RAD.00052 - Positional MRI
  • RAD.00059 - Catheter-based Embolization Procedures for Malignant Lesions Outside the Liver
  • SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
  • SURG.00032 - Patent Foramen Ovale and Left Atrial Appendage Closure Devices for Stroke Prevention
  • SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons
  • SURG.00053 - Unicondylar Interpositional Spacer
  • SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
  • SURG.00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses
  • SURG.00070 - Photocoagulation of Macular Drusen
  • SURG.00072 - Lysis of Epidural Adhesions
  • SURG.00075 - Intervertebral Stabilization Devices
  • SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation
  • SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
  • SURG.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
  • SURG.00107 - Prostate Saturation Biopsy
  • SURG.00113 - Artificial Retinal Devices
  • SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
  • SURG.00127 - Sacroiliac Joint Fusion
  • SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer
  • SURG.00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
  • SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy
  • SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
  • SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
  • SURG.00150 - Leadless Pacemaker
  • SURG.00151 - Balloon Dilation of Eustachian Tubes
  • SURG.00152 - Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
  • SURG.00154 - Microsurgical Procedures for the Treatment of Lymphedema
  • TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation
  • TRANS.00013 - Small Bowel, Small Bowel/Liver and Multivisceral Transplantation
  • TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
  • TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
  • TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
  • TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

Archived Medical Policy Effective 04-07-2021

(The following policy has been archived.)

  • MED.00077 - In-Vivo Analysis of Gastrointestinal Lesions

 

Archived Medical Policies Effective 04-07-2021

(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)

  • GENE.00007 - Cardiac Ion Channel Genetic Testing [Note: Content transferred to CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions]
  • GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment [Note: Content transferred to CG-GENE-22 Gene Expression Profiling for Managing Breast Cancer Treatment]
  • GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy) [Note: Content transferred to CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions]


Archived Medical Policy Effective 06-25-2021

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

  • SURG.00022 - Lung Volume Reduction Surgery [Note: Content transferred to CG-SURG-110 Lung Volume Reduction Surgery

 

New Medical Policies Effective 07-01-2021

(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.00056 - Gene Expression Profiling for Bladder Cancer
  • LAB.00039 - Pooled Antibiotic Sensitivity Testing

 

Revised Medical Policy Effective 07-01-2021

(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.)

  • ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck

 

New Medical Policy Effective 07-01-2021

(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.)

  • TRANS.00037 - Uterine Transplantation

 

Revised Medical Policy Effective 07-03-2021

(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.)

  • LAB.00033 - Protein Biomarkers for the Screening, Detection and Management of Prostate Cancer

 

New Medical Policies Effective 07-17-2021

(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.)

  • LAB.00038 - Cell-free DNA Testing to Aid in the Monitoring of Kidney Transplants for Rejection
  • SURG.00159 - Focal Laser Ablation for the Treatment of Prostate Cancer


Clinical guideline updates

 

Revised Clinical Guideline Effective 02-18-2021

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

  • CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications

 

Archived Clinical Guidelines Effective 04-01-2021

(The following guidelines have been archived and their content has been transferred to an existing Clinical UM Guideline.)

  • CG-GENE-02 - Analysis of RAS Status [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]
  • CG-GENE-03 - BRAF Mutation Analysis [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]
  • CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]
  • CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management]

 

Revised Clinical Guideline Effective 04-01-2021

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

  • CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management [Note: Content from CG-GENE-02, GC-GENE-03, CG-GENE-12, and CG-GENE-20 transferred to this clinical UM guideline. CPT code 0229U moved from GENE.00049 Circulating Tumor DNA Panel Testing for Cancer (Liquid Biopsy)]

 

Revised Clinical Guideline Effective 04-01-2021

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

  • CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules

 

Adopted Clinical Guidelines Effective 04-07-2021

(The following guidelines were previously medical policies and have been adopted and have no significant changes.)

  • CG-GENE-22 - Gene Expression Profiling for Managing Breast Cancer Treatment [Note: Content moved from GENE.00011 Gene Expression Profiling for Managing Breast Cancer Treatment]
  • CG-GENE-23 - Genetic Testing for Heritable Cardiac Conditions [Note: Content moved from GENE.00007 Cardiac Ion Channel Genetic Testing and GENE.00017 Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)]

 

Revised Clinical Guidelines Effective 04-07-2021

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

  • CG-MED-26 - Neonatal Levels of Care
  • CG-SURG-71 - Reduction Mammoplasty
  • CG-SURG-97 - Cardioverter Defibrillators
  • CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

 

Revised Clinical Guidelines Effective 04-07-2021

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

  • CG-DME-06 - Pneumatic Compression Devices for Lymphedema
  • CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
  • CG-GENE-07 - BCR-ABL Mutation Analysis
  • CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
  • CG-GENE-09 - Genetic Testing for CHARGE Syndrome
  • CG-GENE-16 - BRCA Genetic Testing
  • CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
  • CG-MED-88 - Preimplantation Genetic Diagnosis Testing
  • CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
  • CG-SURG-09 - Temporomandibular Disorders
  • CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery
  • CG-SURG-99 - Panniculectomy and Abdominoplasty
  • CG-SURG-104 - Intraoperative Neurophysiological Monitoring
  • CG-TRANS-02 - Kidney Transplantation

 

Revised Clinical Guidelines Effective 04-17-2021

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

  • 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 Guidelines Effective 07-01-2021

(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.)

 

Revised Clinical Guidelines Effective 07-17-2021

(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-DME-06 - Pneumatic Compression Devices for Lymphedema
  • CG-SURG-107 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)

 

1095-0421-PN-NY

 

PUBLICATIONS: April 2021 Newsletter