Medical Policy and Clinical Guideline Updates

These updates list the new and/or revised 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 01-31-2019

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

• DRUG.00071 - Pembrolizumab (Keytruda®)
• DRUG.00088 - Atezolizumab (Tecentriq®)
• OR-PR.00003 - Microprocessor Controlled Lower Limb Prostheses

 

Revised Medical Policy Effective 02-27-2019

(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 02-27-2019

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

• ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
• DME.00025 - Self-Operated Spinal Unloading Devices
• DRUG.00013 - Administration of Immunoglobulin as a Treatment of Recurrent Spontaneous Abortion
• DRUG.00027 - Ziconotide Intrathecal Infusion (Prialt®) for Severe Chronic Pain
• DRUG.00078 - Proprotein Convertase Subtilisin Kexin 9 (PCSK9) Inhibitors
• DRUG.00080 - Monoclonal Antibodies for the Treatment of Eosinophilic Conditions
• DRUG.00081 - Eteplirsen (Exondys 51®)
• DRUG.00082 - Daratumumab (DARZALEX®)
• GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
• GENE.00016 - Gene Expression Profiling for Colorectal Cancer
• GENE.00034 - SensiGene® Fetal RhD Genotyping Test
• GENE.00036 - Genetic Testing for Hereditary Pancreatitis
• GENE.00037 - Genetic Testing for Macular Degeneration
• GENE.00039 - Genetic Testing for Frontotemporal Dementia (FTD)
• GENE.00046 - Prothrombin G20210A (Factor II) Mutation Testing
• LAB.00024 - Immune Cell Function Assay
• LAB.00034 - Serological Antibody Testing for Helicobacter Pylori
• MED.00002 - Selected Sleep Testing Services
• MED.00007 - Prolotherapy for Joint and Ligamentous Conditions
• MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
• MED.00065 - Hepatic Activation Therapy
• MED.00074 - Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data
• 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.00122 - Wilderness Programs
• RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
• RAD.00053 - Cervical and Thoracic Discography
• REHAB.00003 - Hippotherapy
• SURG.00007 - Vagus Nerve Stimulation
• SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
• SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease and Dysphagia
• SURG.00073 - Epiduroscopy
• SURG.00079 - Nasal Valve Suspension
• SURG.00097 - Vertebral Body Stapling for the Treatment of Scoliosis in Children and Adolescents
• 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.00106 - Ablative Techniques as a Treatment for Barrett’s Esophagus
• SURG.00111 - Axial Lumbar Interbody Fusion
• SURG.00112 - Occipital Nerve and Supraorbital Nerve Stimulation
• SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
• SURG.00123 - Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
• SURG.00138 - Laser Treatment for Onychomycosis
• SURG.00146 - Extracorporeal Carbon Dioxide Removal
• THER-RAD.00008 - Neutron Beam Radiotherapy
• THER-RAD.00009 - Intraocular Epiretinal Brachytherapy
• TRANS.00004 - Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)
• TRANS.00008 - Liver Transplantation
• TRANS.00009 - Lung and Lobar Transplantation
• TRANS.00010 - Autologous and Allogeneic Pancreatic Islet Cell Transplantation
• TRANS.00026 - Heart/Lung Transplantation
• TRANS.00033 - Heart Transplantation

 

Archived Medical Policies Effective 03-21-2019

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

• SURG.00115 - Keratoprosthesis [Note: Content transferred to CG-SURG-94 Keratoprosthesis]
• SURG.00117 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention [Note: Content transferred to CG-SURG-95 Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention]
• SURG.00136 - Intraocular Telescope [Note: Content transferred to CG-SURG-96 Intraocular Telescope]

 

New Medical Policy Effective 07-20-2019

(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.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus

 

Revised Medical Policies Effective 07-20-2019

(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.)

• MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting
• SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
• TRANS.00035 - Mesenchymal Stem Cell Therapy for the Treatment of Joint and Ligament Disorders, Autoimmune, Inflammatory and Degenerative Diseases

Clinical Guideline updates

 

Revised Clinical Guidelines Effective 01-31-2019

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

• CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)
• CG-DRUG-99 - Elotuzumab (Empliciti™)
• CG-SURG-27 - Sex Reassignment Surgery
• CG-SURG-83 - Bariatric Surgery and Other Treatments for Clinically Severe Obesity

 

Revised Clinical Guidelines Effective 02-27-2019

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

• CG-DRUG-106 - Brentuximab Vedotin (Adcetris®)
• CG-SURG-77 - Refractive Surgery

 

Revised Clinical Guidelines Effective 02-27-2019

(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-BEH-14 - Intensive In-home Behavioral Health Services
• CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
• CG-DME-10 - Durable Medical Equipment
• 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-43 - High Frequency Chest Compression Devices for Airway Clearance
• CG-DRUG-01 - Off-Label Drug and Approved Orphan Drug Use
• CG-DRUG-28 - Alglucosidase alfa (Lumizyme®)
• CG-DRUG-29 - Hyaluronan Injections
• CG-DRUG-43 - Natalizumab (Tysabri®)
• CG-DRUG-82 - Prostacyclin Infusion Therapy and Inhalation Therapy for Treatment of Pulmonary Arterial Hypertension
• CG-DRUG-83 - Growth Hormone
• CG-DRUG-84 - Belimumab (Benlysta®)
• CG-DRUG-85 - Tesamorelin (Egrifta®)
• CG-DRUG-86 - Ocriplasmin (Jetrea®) Intravitreal Injection Treatment
• CG-DRUG-93 - Sarilumab (Kevzara®)
• CG-LAB-13 - Skin Nerve Fiber Density Testing
• CG-MED-23 - Home Health
• CG-OR-PR-05 - Myoelectric Upper Extremity Prosthetic Devices
• CG-SURG-03 - Blepharoplasty, Blepharoptosis Repair, and Brow Lift
• CG-SURG-70 - Gastric Electrical Stimulation
• CG-SURG-71 - Reduction Mammaplasty
• CG-SURG-72 - Endothelial Keratoplasty
• CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
• CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Noncoronary)

 

Adopted Clinical Guidelines Effective 03-21-2019

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

• CG-SURG-94 - Keratoprosthesis [Note: Content moved from SURG.00115 Keratoprosthesis.]
• CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention [Note: Content moved from SURG.00117 Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention.]
• CG-SURG-96 - Intraocular Telescope [Note: Content moved from SURG.00136 Intraocular Telescope.]

 

Revised Clinical Guideline Effective 07-01-2019

(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-DRUG-106 - Brentuximab Vedotin (Adcetris®)

 

Revised Clinical Guidelines Effective 07-20-2019

(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-MED-73 - Hyperbaric Oxygen Therapy (Systemic/Topical)
• CG-SURG-27 - Sex Reassignment Surgery