Medical policy updates and 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.

 

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 Policy Effective 05-20-2021

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

• TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors

Revised Medical Policies Effective 06-12-2021

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

• OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
• SURG.00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
• SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy

Revised Medical Policy Effective 07-01-2021

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

• MED.00098 - Hyperoxemic Reperfusion Therapy

 

Revised Medical Policies Effective 07-01-2021

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

• GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
• LAB.00011 - Analysis of Proteomic Patterns
• SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents

 

Revised Medical Policy Effective 07-07-2021

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

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

 

Revised Medical Policies Effective 07-07-2021

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

• ADMIN.00002 - Preventive Health Guidelines
• ADMIN.00004 - Medical Necessity Criteria
• ADMIN.00005 - Investigational Criteria
• ADMIN.00007 – Immunizations
• ANC.00006 - Biomagnetic Therapy
• ANC.00007 - Cosmetic and Reconstructive Services: Skin Related
• DME.00024 - Transtympanic Micropressure
• DME.00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
• DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
• DME.00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
• DME.00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
• DME.00042 - Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
• GENE.00010 - Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
• GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
• GENE.00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
• GENE.00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
• LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
• LAB.00031 - Advanced Lipoprotein Testing
• LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
• MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
• MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
• MED.00110 - Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications
• MED.00127 - Chelation Therapy
• MED.00131 - Electronic Home Visual Field Monitoring
• MED.00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
• MED.00133 - Ingestion Event Monitors
• OR-PR.00005 - Upper Extremity Myoelectric Orthoses
• OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
• RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
• RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
• SURG.00005 - Partial Left Ventriculectomy
• SURG.00007 - Vagus Nerve Stimulation
• SURG.00010 - Treatments for Urinary Incontinence
• SURG.00045 - Extracorporeal Shock Wave Therapy
• SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
• SURG.00071 - Percutaneous and Endoscopic Spinal Surgery
• SURG.00076 - Nerve Graft after Prostatectomy
• SURG.00084 - Implantable Middle Ear Hearing Aids
• SURG.00105 - Bicompartmental Knee Arthroplasty
• SURG.00111 - Axial Lumbar Interbody Fusion
• SURG.00116 - High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
• SURG.00118 - Bronchial Thermoplasty
• SURG.00120 - Internal Rib Fixation Systems
• SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
• SURG.00126 - Irreversible Electroporation
• SURG.00134 - Interspinous Process Fixation Devices
• SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
• SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
• SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
• SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
• THER-RAD.00012 - Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
• TRANS.00035 - Other Stem Cell Therapy

Archived Medical Policy Effective 07-07-2021

(The following policy has been archived and has been replaced by AIM guidelines.)

• RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification

 

Archived Medical Policies Effective 07-07-2021

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

• DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting [Note: Content transferred to CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting]
• DME.00034 - Standing Frames [Note: Content transferred to CG-DME-49 Standing Frames]

 

Archived Medical Policies Effective 07-07-2021

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

• GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases]
• GENE.00046 - Prothrombin (Factor II) Genetic Testing [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases]

 

Revised Medical Policy Effective 07-10-2021

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

• SURG.00095 - Viscocanalostomy and Canaloplasty

 

Archived Medical Policy Effective 09-12-2021

(The following policy has been archived and its content has been transitioned to an AIM guideline and to a new Clinical UM Guideline.)

• SURG.00127 - Sacroiliac Joint Fusion [Note: Content for minimally invasive sacroiliac joint fusion transitioned to AIM guidelines and content for open sacroiliac joint fusion moved to CG-SURG-111 Open Sacroiliac Joint Fusion]

 

New Medical Policy Effective 10-01-2021

(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.)

• GENE.00057 - Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

 

Revised Medical Policies Effective 10-01-2021

(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.)

• DME.00012 - Intrapulmonary Percussive Ventilation Devices
• LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
• SURG.00155 - Cryoneurolysis

 

New Medical Policies Effective 10-02-2021

(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.00041 - Machine Learning Derived Probability Score for Rapid Kidney Function Decline
• MED.00137 - Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion

 

Revised Medical Policy Effective 10-02-2021

(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.)

• MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

 

Revised Medical Policy Effective 10-16-2021

(The policies 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.)

• TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

 

Clinical guideline updates

 

Revised Clinical Guideline Effective 05-20-2021

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

• CG-SURG-27 - Gender Affirming Surgery

 

Revised Clinical Guideline Effective 07-01-2021

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

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

 

Archived Clinical Guideline Effective 07-07-2021

(The following guideline has been archived.)

• CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome

 

Revised Clinical Guidelines Effective 07-07-2021

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

• CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
• CG-GENE-13 - Genetic Testing for Inherited Diseases [Note: Content moved from GENE.00042 Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome and GENE.00046 Prothrombin (Factor II) Genetic Testing]
• CG-SURG-12 - Penile Prosthesis Implantation

 

Revised Clinical Guidelines Effective 07-07-2021

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

• CG-DME-45 - Ultrasound Bone Growth Stimulation
• CG-DME-46 - Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
• CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
• CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
• CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation and Atrial Flutter (Radiofrequency and Cryoablation)
• CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
• CG-MED-77 - SPECT/CT Fusion Imaging
• CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
• CG-SURG-05 - Maze Procedure
• CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
• CG-SURG-34 - Diagnostic Infertility Surgery
• CG-SURG-35 - Intracytoplasmic Sperm Injection (ICSI)
• CG-SURG-50 - Assistant Surgeons
• CG-SURG-71 - Reduction Mammaplasty
• CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
• CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery
• CG-SURG-85 - Hip Resurfacing
• CG-SURG-86 - Endovascular/ Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
• CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
• CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
• CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus
• CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Revised Clinical Guidelines Effective 07-17-2021

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

• CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Revised Clinical Guideline Effective 10-01-2021

(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-12 - Penile Prosthesis Implantation

 

Revised Clinical Guidelines Effective 10-16-2021

(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-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
• CG-SURG-71 - Reduction Mammaplasty

 

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