 Provider News New YorkFebruary 2020 Empire Provider NewsBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) Commercial Risk Adjustment (CRA) contracts with Inovalon -- an independent company that provides secure, clinical documentation services -- to help us comply with provisions of the Affordable Care Act (ACA) that require us to assess members’ relative health risk level and report to CMS on those conditions. Your offices have been receiving Inovalon SOAP ( Subjective; Objective; Assessment; and Plan – these are health assessments) packets all year long as part of our risk adjustment cycle, asking for the physicians’ help with completing health assessments for some of their patients who are our members.
Incentives for submitting SOAP’s/Health Assessments
SOAPs submitted as paper are eligible for a $50 incentive; SOAPs submitted electronically through Inovalon’s ePASS system are eligible for a $100 incentive.
Submission Deadline and Important Reminder
While the dates of service for the patient visits must have been by December 31, 2019, the SOAP notes/Health Assessments can be submitted up until February 15, 2020. We will still pay the incentive payments for these submissions through February 15, 2020.
Questions or assistance with SOAPs
Need help with ePASS or have questions? Simply email your inquiry to Inovalon at ePASSsupport@inovalon.com with your name, organization, contact information, and any questions that you might have. Trained representatives are available to assist you. If you prefer to reach Inovalon by phone, please call 1-877-448-8125, Monday - Friday, 8 am - 9 pm ET; Saturday - Sunday, 10 am - 6 pm ET.
If you have any questions regarding our risk adjustment process, please contact our CRA Network Education Representative who supports your area: Alicia.Estrada@anthem.com. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on or after January 1, 2020, Empire BlueCross (“Empire”) will consider claims for NYSHIP members receiving immunizations in an outpatient hospital setting.
For dates of service prior to January 1, 2020, claims should be submitted to United Health Care (UHC), NYSHIP’s medical benefit administrator.
All claims will be subject to standard medical necessity guidelines and contract limitations. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The parent company of Empire BlueCross BlueShield (“Empire”), Anthem, Inc. is collaborating with leading organizations on a new school-based initiative called Shine Light on Depression to help tackle the issue of teen depression and suicide in middle and high school youth nationwide. The Shine Light on Depression e-toolkit (e.g., website) will provide school communities with free, ready-to-use tools designed to raise awareness of depression and suicide prevention in a positive, fact-based, and inclusive manner. This approach will help build a community in which there is open discussion and appropriate vocabulary about the subject of depression and places it in the broader context of good mental health. The e-toolkit features customizable classroom lessons to empower educators to lead effective depression awareness programs, family-community workshop materials to help adults and families talk about how to support teens, and teen club resources that empower students to lead activities and help each other by talking and listening. With 24,053 secondary schools in the U.S., the Shine Light on Depression e-toolkit has the potential to impact large numbers of individuals who are at risk of depression and suicide and support schools in meeting state teaching mandates. Visit Shine Light on Depression to learn more.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Advanced Imaging: Vascular Imaging Clinical Appropriateness Guidelines.
Updates by section:
Aneurysm of the abdominal aorta or iliac arteries
- Added new indication for asymptomatic enlargement by imaging
- Clarified surveillance intervals for stable aneurysms as follows:
- o Treated with endografts, annually
- o Treated with open surgical repair, every 5 years
Stenosis or occlusion of the abdominal aorta or branch vessels, not otherwise specified
- o Added surveillance indication and interval for surgical bypass grafts
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective for dates of service on and after May 17, 2020, the following updates will apply to the AIM Musculoskeletal Program: Joint Surgery and Spine Surgery Clinical Appropriateness Guidelines.
Joint Surgery Updates by section:
- Shoulder Arthroplasty
- o Added steroid injection for all joints exclusion based on panel recommendation
- o Added exclusions for use of xenografts or biologic scaffold for augmentation or bridging reconstruction, use of platelet rich plasma or other biologics and concomitant subacromial decompression
- o Removed indication for subacromial impingement with rotator cuff tear
- Hip arthroplasty
- o Added exclusion for steroid injection for joint being replaced within the past 6 weeks
- o Added labral tear indication
- Knee Arthroscopy and Open Procedures
- o Added chondroplasty indication
- o Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella
- o Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section
- Code changes
- o Added CPT codes 27425, 27570
Spine Surgery Updates by section:
- No criteria changes
- Code changes only
- o Added CPT codes 0200T, 0201T
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com. Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number at 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here. 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.
Medical Policy Updates
Revised Medical Policy Effective 11-12-2019
(The following policy was revised to expand medical necessity indications or criteria.)
- BEH.00002 - Transcranial Magnetic Stimulation
Revised Medical Policy Effective 11-12-2019
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- MED.00124 - Tisagenlecleucel (Kymriah®)
Archived Medical Policy Effective 12-14-2019
(The following policy has been archived and has been replaced by AIM guidelines.)
- RAD.00054 - MRI of the Bone Marrow
Revised Medical Policy Effective 12-14-2019
(The following policy was revised to expand medical necessity indications or criteria.)
- SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
Revised Medical Policies Effective 12-18-2019
(The following policies were revised to expand medical necessity indications or criteria.)
- SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- TRANS.00033 - Heart Transplantation
Revised Medical Policies Effective 12-18-2019
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ADMIN.00001 - Medical Policy Formation
- DME.00025 - Self-Operated Spinal Unloading Devices
- 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.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
- LAB.00036 - Multiplex Autoantigen Microarray Testing for Systemic Lupus Erythematosus
- 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.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
- RAD.00012 - Ultrasound for the Evaluation of the Paranasal Sinuses
- RAD.00036 - MRI of the Breast
- RAD.00053 - Cervical and Thoracic Discography
- RAD.00065 - Radiostereometric Analysis (RSA)
- REHAB.00003 - Hippotherapy
- SURG.00019 - Transmyocardial Revascularization
- SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
- SURG.00073 - Epiduroscopy
- SURG.00079 - Nasal Valve Suspension
- 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.00103 - Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
- SURG.00111 - Axial Lumbar Interbody Fusion
- SURG.00112 - Occipital Nerve and Supraorbital Nerve Stimulation
- SURG.00121 - Transcatheter Heart Valve Procedures
- SURG.00123 - Transmyocardial/Perventricular Device Closure of Ventricular Septal Defects
- SURG.00130 - Annulus Closure After Discectomy
- SURG.00138 - Laser Treatment of 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.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.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
Revised Medical Policies Effective 12-31-2019
(The following policies were updated with CPT/HCPCS procedure code updates.)
- GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
- GENE.00011 - Gene Expression Profiling for Managing Breast Cancer Treatment
- GENE.00018 - Gene Expression Profiling for Cancers of Unknown Primary Site
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing
- LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00030 - Measurement of Serum Concentrations of Monoclonal Antibody Drugs and Antibodies to Monoclonal Antibody Drugs
- RAD.00057 - Near-Infrared Coronary Imaging and Near-Infrared Intravascular Ultrasound Coronary Imaging
- SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
- SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
- SURG.00144 - Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia
- SURG.00150 - Leadless Pacemaker
- SURG.00153 - Cardiac Contractility Modulation Therapy
Revised Medical Policies Effective 01-11-2020
(The following policies were updated with CPT/HCPCS procedure code updates.)
- MED.00125 - Biofeedback and Neurofeedback
- RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
Revised Medical Policies Effective 01-11-2020
(The following policies were revised to expand medical necessity indications or criteria.)
- ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
- SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- SURG.00127 - Sacroiliac Joint Fusion
Revised Medical Policy Effective 01-11-2020
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
Revised Medical Policy Effective 02-01-2020
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- MED.00110 - Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment, and Soft Tissue Grafting, and Regenerative Therapy
Transitioned Medical Policies Effective 02-05-2020
(The following policies have been transitioned to Pharmacy and Therapeutics (P&T) Clinical Criteria.)
- MED.00123 - Axicabtagene ciloleucel (Yescarta®) [Transitioned to NG-CC-0151 Yescarta (axicabtagene ciloleucel)]
- MED.00124 - Tisagenlecleucel (Kymriah®) [Transitioned to ING-CC-0150 Kymriah (tisagenlecleucel)]
Revised Medical Policy Effective 02-05-2020
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- MED.00117 - Autologous Cell Therapy for the Treatment of Damaged Myocardium
Archived Medical Policies Effective 02-05-2020
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- GENE.00006 - Epidermal Growth Factor Receptor (EGFR) Testing [Note: Content transferred to CG-GENE-20 Epidermal Growth Factor Receptor (EGFR) Testing.]
- GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers [Note: Content transferred to CG-GENE-19 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers.]
- MED.00109 - Corneal Collagen Cross-Linking [Note: Content transferred to CG-SURG-105 Corneal Collagen Cross-Linking.]
- RAD.00023 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications [Note: Content transferred to CG-MED-87 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications.]
- SURG.00122 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone [Note: Content transferred to CG-SURG-106 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.]
New Medical Policy Effective 02-05-2020
(The policy below was created and had no significant changes to the policy position or criteria.)
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling [Note: Gene panel codes moved from GENE.00001, GENE.00012, GENE.00025, GENE.00028, GENE.00029, GENE.00030, GENE.00035, and GENE.00043.]
Revised Medical Policies Effective 05-01-2020
(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.)
- GENE.00025 - Proteogenomic Testing for the Evaluation of Malignancies [Note: Content for molecular profiling and gene panels transferred to GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling [Note: Gene panel codes moved from GENE.00001, GENE.00012, GENE.00025, GENE.00028, GENE.00029, GENE.00030, GENE.00035, and GENE.00043.]
- SURG.00007 - Vagus Nerve Stimulation
- SURG.00032 - Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
Archived Medical Policies Effective 02-05-2020
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- GENE.00001 - Genetic Testing for Cancer Susceptibility [Note: Content transferred to CG-GENE-14 Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
- GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
- GENE.00028 - Genetic Testing for Colorectal Cancer Susceptibility [Note: Content transferred to CG-GENE-15 Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
- GENE.00029 - Genetic Testing for Breast and/or Ovarian Cancer Syndrome [Note: Content transferred to CG-GENE-16 BRCA Testing for Breast and/or Ovarian Cancer Syndrome. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
- GENE.00030 - Genetic Testing for Endocrine Gland Cancer Susceptibility [Note: Content transferred to CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
- GENE.00035 - Genetic Testing for TP53 Mutations [Note: Content transferred to CG-GENE-18 Genetic Testing for TP53 Mutations. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases. Gene panels moved to GENE.00052 Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling.]
Revised Medical Policies Effective 05-16-2020
(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.)
- SURG.00028 - Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH)
- SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
Clinical Guideline Updates
Revised Clinical Guideline Effective 12-18-2019
(The following adopted guideline was revised to expand medical necessity indications or criteria.)
- CG-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
Revised Clinical Guidelines Effective 12-18-2019
(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-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-40 - Noninvasive Electrical Bone Growth Stimulation of the Appendicular Skeleton
- CG-DME-43 - High Frequency Chest Compression Devices for Airway Clearance
- 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-27 - Gender Reassignment Surgery
- CG-SURG-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver [Note: Content for radiofrequency ablation to treat tumors outside the liver moved from CG-SURG-62 Radiofrequency Ablation to Treat Tumors Outside the Liver]
- CG-SURG-71 - Reduction Mammoplasty
- CG-SURG-72 - Endothelial Keratoplasty
- CG-SURG-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-SURG-77 - Refractive Surgery
- CG-SURG-94 - Keratoprosthesis
- CG-SURG-95 - Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention
- CG-SURG-96 - Intraocular Telescope
- CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Non-Coronary)
Archived Clinical Guideline Effective 12-18-2019
(The following adopted clinical guideline has been archived and its content has been transferred to an existing Clinical UM Guideline.)
- CG-SURG-62 - Radiofrequency Ablation to Treat Tumors Outside the Liver [Note: Content merged into to CG-SURG-61 Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver]
Revised Clinical Guidelines Effective 12-31-2019
(The following adopted clinical guidelines were updated with CPT/HCPCS procedure code updates.)
- CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
- CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
- CG-MED-77 - SPECT/CT Fusion Imaging
- CG-SURG-86 - Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
Revised Clinical Guideline Effective 01-11-2020
(The following adopted clinical guideline was updated with CPT/HCPCS procedure code updates.)
- CG-REHAB-11 - Cognitive Rehabilitation
Adopted Clinical Guidelines Effective 02-05-2020
(The following guidelines were previously medical policies and have been adopted and have no significant changes.)
- CG-GENE-13 - Genetic Testing for Inherited Diseases [Note: Content moved from GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent and GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases.]
- CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management [Note: Content moved from GENE.00001 Genetic Testing for Cancer Susceptibility.]
- CG-GENE-15 - Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis [Note: Content moved from GENE.00028 Genetic Testing for Colorectal Cancer Susceptibility.]
- CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome [Note: Content moved from GENE.00029 Genetic Testing for Breast and/or Ovarian Cancer Syndrome.]
- CG-GENE-17 - RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility [Note: Content moved from GENE.00030 Genetic Testing for Endocrine Gland Cancer Susceptibility.]
- CG-GENE-18 - Genetic Testing for TP53 Mutations [Note: Content moved from GENE.00035 Genetic Testing for TP53 Mutations.]
- CG-GENE-19 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers [Note: Content for genotype testing for single polymorphisms of metabolizing enzymes for specific drugs moved from GENE.00045 Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers.]
- CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing [Note: Content moved from GENE.00006 Epidermal Growth Factor Receptor (EGFR) Testing.]
- CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications [Note: Content moved from RAD.00023 Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications.]
- CG-SURG-105 - Corneal Collagen Cross-Linking [Note: Content moved from MED.00109 Corneal Collagen Cross-Linking.]
- CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone [Note: Content moved from SURG.00122 Venous Angioplasty with or without Stent Placement or Venous Stenting Alone.]
Revised Clinical Guideline Effective 05-01-2020
(The following adopted guideline were revised and might result in services that were previously covered but may now be found to be not medically necessary.)
- CG-GENE-13 - Genetic Testing for Inherited Diseases [Note: Content moved from GENE.00012 Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent and GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases.]
- CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management [Note: Content moved from GENE.00001 Genetic Testing for Cancer Susceptibility.]
- CG-MED-68 - Therapeutic Apheresis
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Claims that are submitted for laboratory services subject to the Clinical Laboratory Improvement Amendments (CLIA) 1988 federal statute and regulations require additional information to be considered for payment.
In New York, through Clinical Laboratory Reference System accreditation or through the Physician Office Laboratory Evaluation Program (POLEP), laboratories that meet state requirements and/or CLIA accreditation requirements are awarded a CLIA number. More information regarding this requirement can be found at https://www.wadsworth.org/regulatory/clep/clinical-labs.
A valid CLIA Certificate Identification number is required for reimbursement of clinical laboratory services reported on a CMS-1500 claim form (or its electronic equivalent) beginning May 1, 2020. The CLIA Certificate Identification number must be submitted in one of the following ways:
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Claim Format and Elements
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CLIA Number Location Options
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Referring Provider Name and National Provider Identifier (NPI) Number Location Options
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CMS-1500
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Must be represented in field 23
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Submit the referring provider name and NPI number in fields 17 and 17b, respectively.
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Electronic transaction 837 Professional; Health Insurance Portability and Accountability Act (HIPAA) Version 5010
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Must be represented in the 2300 loop, REF02 element, with qualifier of “X4” in REF01
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Submit the referring provider name and NPI number in the 2310A loop, NM1 segment.
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Providers who have obtained a CLIA Waiver or Provider Performed Microscopy Procedure accreditation must include the “QW” modifier when any CLIA Waived laboratory service is reported on a CMS-1500 claim form in order for the procedure to be evaluated to determine eligibility for benefit coverage.
Laboratory procedures are only covered and therefore payable if rendered by an appropriately licensed or certified laboratory. Therefore, any claim that does not contain the CLIA ID will be considered incomplete and rejected beginning May 1, 2020.
If you have additional questions, please call the telephone number on the back of the member’s identification card. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The following Clinical Criteria documents were endorsed at the November 15, 2019 Clinical Criteria meeting. To access the clinical criteria information please click here.
Empire BlueCross BlueShield’s (“Empire”) pre-service clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Oncology drugs will be managed by AIM Specialty Health (AIM), a separate company.
Revised Clinical Criteria effective December 16, 2019
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0003 Immunoglobulins
- ING-CC-0041 Complement Inhibitors
- ING-CC-0042 Monoclonal Antibodies to Interleukin-17
- ING-CC-0063 Stelara (ustekinumab)
- ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0075 Rituximab Agents for Non-Oncology Indications
- ING-CC-0124 Keytruda (pembrolizumab)
- ING-CC-0127 Darzalex (daratumumab)
- ING-CC-0128 Tecentriq (atezolizumab)
- ING-CC-0133 Aliqopa (copanlisib)
Revised Clinical Criteria effective December 16, 2019
The following current clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0006 Hyaluronan Injections
- ING-CC-0035 Duopa (carbidopa and levodopa enteral suspension)
- ING-CC-0039 GamaSTAN [(immune globulin (human)]
- ING-CC-0040 Prialt (ziconotide)
- ING-CC-0047 Trogarzo (ibalizumab-uiyk)
- ING-CC-0049 Radicava (edaravone)
- ING-CC-0074 Akynzeo (fosnetupitant and palonosetron) for Injection
- ING-CC-0079 Strensiq (asfotase alfa)
- ING-CC-0090 Ixempra (ixabepilone)
- ING-CC-0100 Istodax (romidepsin)
- ING-CC-0103 Faslodex (fulvestrant)
- ING-CC-0108 Halaven (eribulin)
- ING-CC-0110 Perjeta (pertuzumab)
- ING-CC-0115 Kadcyla (ado-trastuzumab)
Revised Clinical Criteria effective February 1, 2020
The following current clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0073 Alpha-1 Proteinase Inhibitor Therapy
Revised Clinical Criteria effective February 5, 2020
The following new clinical criteria were revised to expand medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
|
Clinical or Coverage Guideline
|
Clinical Criteria
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS or CPT Code(s)
|
|
MED.00123
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ING-CC-0151
|
Yescarta (axicabtagene ciloleucel)
|
Yescarta
|
0537T, 0538T, 0539T, 0540T, Q2041,
XW033C3, XW043C3
|
Revised Clinical Criteria effective February 5, 2020
The following new clinical criteria were revised with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
|
Clinical or Coverage Guideline
|
Clinical Criteria
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS or CPT Code(s)
|
|
MED.00124
|
ING-CC-0150
|
Kymriah (tisagenlecleucel)
|
Kymriah
|
0537T, 0538T, 0539T, 0540T, Q2042,
XW033C3, XW043C3
|
Revised Clinical Criteria effective May 1, 2020
The following current clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary.
- ING-CC-0002 Colony Stimulating Factor Agents
- ING-CC-0003 Immunoglobulins
- ING-CC-0034 Hereditary Angioedema Agents
- ING-CC-0041 Complement Inhibitors
- ING-CC-0042 Monoclonal Antibodies to Interleukin-17
- ING-CC-0043 Monoclonal Antibodies to Interleukin-5
- ING-CC-0048 Spinraza (nusinersen)
- ING-CC-0050 Monoclonal Antibodies to Interleukin-23
- ING-CC-0062 Tumor Necrosis Factor Antagonists
- ING-CC-0063 Stelara (ustekinumab)
- ING-CC-0064 Interleukin-1 Inhibitors
- ING-CC-0065 Agents for Hemophilia A and von Willebrand Disease. [Note: Content for Agents for Hemophilia B moved to ING-CC-0148 and content for Select Clotting Agents for Bleeding Disorders moved to ING-CC-0149.]
- ING-CC-0066 Monoclonal Antibodies to Interleukin-6
- ING-CC-0071 Entyvio (vedolizumab)
- ING-CC-0072 Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
- ING-CC-0078 Orencia (abatacept)
- ING-CC-0150 Kymriah (tisagenlecleucel)
Revised Clinical Criteria effective May 1, 2020
The following new clinical criteria were revised with no significant change to the medical necessity indications or criteria. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
|
Clinical or Coverage Guideline
|
Clinical Criteria
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS or CPT Code(s)
|
|
ING-CC-0065
|
ING-CC-0148
|
Agents for Hemophilia B
|
Coagulation Factor IX, Human plasma-derived
· Alphanine SD, Mononine
Factor IX Complex, human plasma-derived
· Bebulin, Profilnine SD
Factor IX Recombinant
· Benefix, Ixinity, Rixubis
Coagulation Factor IX-Long-Acting
· Recombinant, Albumin Fusion Protein--- Idelvion
· Recombinant coagulation factor IX, Fc Fusion Protein --- Alprolix
· Recombinant coagulation factor IX, GlycoPEGylated --- Rebinyn
|
J7193, J7194, J7195, J7200, J7201, J7202, J7203
|
Revised Clinical Criteria effective May 1, 2020
The following new clinical criteria were revised and might result in services that were previously covered but may now be found to be not medically necessary. The table below will assist you in identifying the new document number for the clinical criteria that corresponds with the previous Clinical or Coverage Guideline.
|
Clinical or Coverage Guideline
|
Clinical Criteria
|
Clinical Criteria Name
|
Drug(s)
|
HCPCS or CPT Code(s)
|
|
ING-CC-0065
|
ING-CC-0149
|
Select Clotting Agents for Bleeding Disorders
|
Anti-inhibitor Anti-inhibitor Coagulant Complex
· FEIBA
Coagulation Factor X, Human plasma-derived
· Coagadex
Factor VIIa Recombinant
· Novoseven RT
Factor XIII
· Factor XIII Human plasma-derived ---Corifact
· Factor XIII A subunit Recombinant ---Tretten
Fibrinogen Concentrate
· Human plasma-derived---RiaSTAP
· Human fibrinogen ---Fibryga
|
J7175, J7177, J7178, J7180, J7181 J7189, J7198
|
| |
|
|
|
|
|
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective with dates of service on and after April 1, 2020, and in accordance with the IngenioRx Pharmacy and Therapeutic (P&T) process, Empire BlueCross BlueShield will update its drug lists that support commercial health plans.
Updates include changes to drug tiers and the removal of medications from the formulary.
Please note, this update does not apply to the Select Drug List and does not impact Medicaid and Medicare plans.
To ensure a smooth member transition and minimize costs, providers should review these changes and consider prescribing a drug on formulary or on a lower tier, if appropriate.
View a summary of changes here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield’s (“Empire”) Pharmacy Benefit Manager, IngenioRx, Inc., is the registered utilization review agent contracted to begin processing Pharmacy prior authorization requests by the end of Q1 2020.
Please note:
- There are no changes to current prior authorization points of contact/processing staff; systems; or phone and fax lines.
- There are no changes to the Appeals process. Please continue to follow Appeals guidance as indicated in determination notices.
Questions? Please contact the Pharmacy Helpdesk number located on the back of the member ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicaid
Currently, Empire BlueCross BlueShield HealthPlus includes Early and Periodic Screening, Diagnosis and Treatment (EPSDT) component services in the reimbursement of preventive medicine evaluation and management (E&M) visits unless they are appended with Modifier 25 to indicate a significant, separately identifiable E&M service by the same physician on the same date of service.
However, effective May 1, 2020, the following EPSDT component services will be separately reimbursable from the preventive medicine E&M visit:
- Hearing screening with or without the use of an audiometer or other electronic device
- Vision Screening
For additional information, please review the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) reimbursement policy at www.empireblue.com/nymedicaiddoc.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicare
Effective January 1, 2020, General Building Laborers' Local 66 Welfare Fund will offer the Empire MediBlue Freedom (PPO) with Senior Rx Plus Medical and Prescription Drug plan.
Retirees with Medicare Parts A and B are eligible to enroll in the PPO with Senior Rx Plus Medical and Prescription Drug plan. The plan includes the National Access Plus benefit, which allows retirees to receive services from any provider as long as the provider is eligible to receive payments from Medicare. In addition, General Building Laborers' Local 66 Welfare Fund retirees pay the same cost share for both in-network and out-of-network services. The Medicare Advantage plan offers the same hospital and medical benefits that Original Medicare covers and covers additional benefits that Original Medicare does not, such as an annual routine physical exam, hearing, vision, LiveHealth Online tool and SilverSneakers®.
The prefix on General Building Laborers' Local 66 Welfare Fund member ID cards will be XLU. The cards will also show the General Building Laborers' Local 66 Welfare Fund logo and National Access Plus icon.
Providers may submit claims electronically using the electronic payer ID for the Empire BlueCross BlueShield (Empire) plan or submit a UB-04 or CMS-1500 form to Empire. Claims should not be filed with Original Medicare. Contracted and noncontracted providers may call the Provider Services number on the back of the member ID card for benefit eligibility, prior authorization requirements, and any questions about General Building Laborers' Local 66 Welfare Fund member benefits or coverage.
Detailed prior authorization requirements also are available to contracted providers by accessing the Provider Self-Service Tool at https://www.availity.com.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicare
Effective May 1, 2020, the following updates have been made to the policy:
- Empire BlueCross (Empire) allows reimbursement to professional providers and facilities for multiple and bilateral surgery. Reimbursement is based on multiple and bilateral procedure rules in accordance with contracts and/or state guidelines for applicable surgical procedures performed on the same day by the same provider to the same patient.
- Empire also added language under the Multiple Surgery section to state that a single procedure will be subject to a multiple procedure reduction when submitted with multiple units.
Please visit www.empireblue.com/medicareprovider to view the Multiple and Bilateral Surgery reimbursement policy for additional information regarding percentages and reimbursement criteria.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicare
Effective May 1, 2020, Empire BlueCross BlueShield HealthPlus (Empire) has updated the Modifier 62: Co‑Surgeons reimbursement policy to expand the current policy’s language, adding that Empire does not consider surgeons performing different procedures during the same surgical session as co-surgeons, and Modifier 62 is not required.
Assistant surgeon and/or multiple procedures rules and fee reductions apply if a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session.
Please note that assistant surgeon rules do not apply to procedures appropriately billed with Modifier 62.
Please visit www.empireblue.com/medicareprovider to view the Modifier 62: Co-Surgeons reimbursement policy for additional information regarding percentages and reimbursement criteria.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicare
Effective April 1, 2020, Empire BlueCross (Empire) will transition the utilization management of our Medicare Advantage Outpatient Rehabilitation Program from American Specialty Health (ASH) to AIM Specialty Health® (AIM). AIM is a specialty health benefits company. The Outpatient Rehabilitation Program includes physical, occupational and speech therapy services. Empire has an existing relationship with AIM in the administration of other programs.
This transition enables Empire to expand and optimize this program further, ensuring that care aligns with established evidence-based medicine. AIM will follow the clinical hierarchy established by Empire for medical necessity determination. For Medicare Advantage, Empire makes coverage determinations based on guidance from CMS, including national coverage determinations, local coverage determinations, other coverage guidelines and instructions issued by CMS, and legislative changes in benefits. When existing guidance does not provide sufficient clinical detail, AIM will determine medical necessity using an objective, evidence-based process.
AIM will continue to use criteria documented in Empire’s clinical guidelines CG.REHAB.04, CG.REHAB.05 and CG.REHAB.06 for review of these services. These clinical guidelines can be reviewed online at https://www.availity.com by selecting Clinical Resources in the Education and Reference Center under Payer Spaces.
Detailed prior authorization requirements are available online at https://www.availity.com by accessing the Precertification Lookup Tool under Payer Spaces. Contracted and noncontracted providers should call Provider Services at the phone number on the back of the member’s ID card for prior authorization requirements.
Prior authorization review requirements
For outpatient rehabilitation services scheduled to be rendered through March 31, 2020, contact ASH. Any authorizations ASH makes prior to the transition date of April 1, 2020, will be honored, and claims will process accordingly.
For services that are scheduled on or after April 1, 2020, contact AIM to obtain prior authorization. Beginning March 16, 2020, you can start contacting AIM for prior authorization on services to take place on or after April 1, 2020. We strongly encourage that you verify you have obtained prior authorization before scheduling and performing services.
How to place a review request
You can make a review request online via the AIM ProviderPortalSM. This service is available 24/7 to process requests in real time using clinical criteria. Go to https://www.providerportal.com to register. You can also call AIM at 1-800-714-0040, Monday to Friday 8 a.m. to 8 p.m. Eastern time.
For more information
For resources to help your practice get started with the Outpatient Rehabilitation Program, go to https://aimproviders.com/rehabilitation.
Visit the provider website (www.empireblue.com/medicareprovider) for additional information and tools, such as an FAQ, order entry checklists and clinical guidelines.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicare
Empire BlueCross BlueShield communicated to you on June 1, 2019, that we were initiating post-payment reviews for professional emergency room (ER) claims billed with level 5 ER evaluation and management (E/M) codes 99285 and G0384.
The implementation of this policy has been postponed.
This update relates only to the policy announced June 1, 2019. All other current policies applicable to you, including but not limited to other audit or reimbursement policies pertaining to ER claims, are unaffected by this update. We will keep you informed about the initiation of the review process; however, we require proper coding and billing to ensure prompt and accurate payment.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicaid
Effective December 1, 2019, Empire BlueCross BlueShield HealthPlus began denying claims billed with non-covered codes. CPT® and HCPCS codes not included in the current New York State fee schedules are considered non-covered. Covered codes are available at https://www.emedny.org.
Non-covered codes should be billed with a more appropriate code or bundled — not separately reimbursed) with another covered code. Please note this policy notification is specific to the MMC and Child Health Plus programs only.
Provider action
To avoid denials, please ensure that you are billing with the most current applicable CPT codes and HCPCS codes on the current New York State fee schedules.
List of Non-Covered CPT HCPCS Codes can be found at the following hyperlink: https://mediproviders.empireblue.com/ProviderUpdates/NYNY_CAID_PU_NoncoveredCPTHCPCSCodes.pdf.
Questions
If you have questions about this communication, please contact your Provider Relations Representative or the Provider Services team at 1-800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Category: Medicaid
As patient panels grow more diverse and needs become more complex, providers and office staff need more support to help address patients’ needs. Empire BlueCross BlueShield HealthPlus (Empire) wants to help.
Cultural competency resources
We have cultural competency resources available on our provider website. Leveraging content created by the Industry Collaboration Effort (ICE) Cultural and Linguistic Workgroup, the Cultural Competency Training and the Caring for Diverse Populations Toolkit have enhanced content.
- Cultural Competency Training includes:
- o Enhanced content regarding culture including language and the impact on health care.
- o A cultural competency continuum that can help providers assess their level of cultural competency.
- o Guidance on working effectively with interpreters.
- o Comprehensive content on serving patients with disabilities.
- Caring for Diverse Populations Toolkit includes:
- o Comprehensive information on working with diverse patients and effectively supporting culture, language and disabilities in health care delivery.
- o Tools and resources to help mitigate barriers including materials that can be printed and made available for patients in your office.
- o Guidance on regulations and standards for cultural and linguistic services.
In addition, providers can access https://mydiversepatients.com for tools and resources that are accessible from any smartphone, tablet or desktop. Providers will find free continuing medical education courses that cover topics relevant to providing culturally competent care and services for diverse individuals.
Prevalent non-English languages (based on population data)
Like you, Empire wants to effectively serve the needs of diverse patients. It’s important for us all to be aware of the cultural and linguistic needs of our communities, so we are sharing recent data about the prevalent non-English languages spoken by 5 percent or 1,000 individuals in New York. (Source: American Community Survey, 2016 American Community Survey 5-Year Estimates, Table B16001, generated 10/03/2018)
Prevalent non-English languages in NY:
- Arabic
- Chinese includes Mandarin, Cantonese
- Korean
- Russian
- Spanish
Language support services
As a reminder, Empire provides language support services for our members with limited English proficiency (LEP) or hearing, speech or visual impairments. Please see the provider manual at www.empireblue.com/nymedicaiddoc for details on the available services and how to access them.
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