Policy Updates Medical Policy & Clinical GuidelinesCommercialAugust 31, 2019

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 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 Policy Effective 07-30-2019

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

  • MED.00129 - Gene Therapy for Spinal Muscular Atrophy

 

Clinical Guideline Updates

 

Archived Clinical Guideline Effective 10-01-2019

(The following guideline has been archived and has been replaced by AIM guidelines.)

  • CG-MED-80 - Positron Emission Tomography (PET) and PET/CT Fusion

PUBLICATIONS: September 2019 Empire Provider News