 Provider News New YorkJanuary 2021 Empire Provider NewsBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Consumer Assessment of Healthcare Providers and Systems (CAHPS) is a standardized survey conducted between February to May each year to assess consumers’ experience with their provider and health plan. A random sample of your adult and child patients may receive the survey. Over half of the questions used for scoring are directly impacted by providers.
The survey questions are:
- When you needed care right way, how often did you get it?
- How often did you get an appointment for a check-up or routine care as soon as you needed?
- How often was it easy to get the care, tests, or treatment you needed?
- How often did you get an appointment to see a specialist as soon as you needed?
- How often did your personal doctor seem informed and up-to-date about the care you got from other health providers?
- How would you rate your personal doctor?
- How would you rate the specialist you see most often?
To learn more about how you can improve the patient experience review What Matters Most: Improving the Patient Experience, an online course for providers and office staff. This course is available at no cost and is eligible for one CME credit by the American Academy of Family Physicians. The What Matters Most training can be accessed at: www.patientexptraining.com.
Your efforts to create an exceptional care experience for your patients will help to strengthen their healthcare journey.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a reminder , we will update our claim editing software monthly for outpatient facility services throughout 2021 with the majority of maintenance updates occurring quarterly in 2021. These updates will:
- reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers, Revenue Codes) and their associated edits
- include appropriate use of various code combinations, which can include, but are not limited to, procedure code to revenue code, HCPCS to revenue code, type of bill to procedure code, type of bill to HCPCS code, procedure code to modifier, and HCPCS to modifier
- include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
- include updates to reflect coding requirements as designated by industry standard sources such as The National Uniform Billing Committee (NUBC)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a reminder, we will update our claim editing software monthly for professional services throughout 2021 with the majority of maintenance updates occurring quarterly in February, May, August and November of 2021. These updates will:
- reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
- include updates to National Correct Coding Initiative edits (NCCI) and medically unlikely edits (MUEs)
- include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
- include assistant surgeon eligibility in accordance with the policy
- include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)
- apply to any provider, provider group (tax identification number) and/or across providers and claim type (professional/facility) for the same member
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. You no longer need to pick up the phone or head to the fax machine to check the status of an authorization request or update a case. Empire BlueCross BlueShield (“Empire”) has added new features to Interactive Care Reviewer (ICR), our online medical and behavioral health authorization tool to improve your digital self-service experience.
Do you need to update a case that was submitted by phone or fax? Now you can add clinical notes and make other updates to these authorization requests through ICR. To make the update you need to have the Authorization & Referral Request role assigned to you by your Availity Administrator.
- To locate the case, log on to the Availity Portal and select Patient Registration > Authorizations & Referrals, then choose Auth/Referral Inquiry.
- Search for the case in ICR by Member, Reference/Authorization Request Number, or by Date Range.
- From the ICR Case Overview screen select Update Case to update service codes, provider information or clinical notes. If you only need to make changes or add to your notes, select Update Clinical. Select Submit Update to complete the request.
We’ve removed the guesswork from the notes that are recommended for many standard authorization requests. ICR provides a check list of the supporting clinical information that will assist Empire with completing the review. The list is located on the Clinical Details screen. You can upload notes, images and photos directly through ICR. You can include the documentation immediately or you can submit your request then return to the case in ICR later and select Update Clinical to add the missing information.
- Check the status of a submitted case at a glance. The ICR UM tracker, located on the Case Overview screen provides a quick view of where the case is in the review process. You can view when Empire received the request, when the clinical review is underway and completed and the final decision.
Additionally, we’ve added a new application to Payer Spaces – Chat with Payer that you can use to check the status of a submitted authorization request. This is a great option if you don’t have the role assignments required to access ICR and research a case.
To access the Chat with Payer application from Availity’s home page, select Payer Spaces > Chat with Payer. Complete the form with the required information. You need to include the patient name, birth date and health plan member ID number. Choose Authorization Status as your topic for chat to conduct a live chat with a representative.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In this 60-minute webinar, you will learn how to use Availity's* Attachment tools to submit and track supporting documentation electronically to Empire BlueCross BlueShield (“Empire”) and affiliate payers.
We will explore new key workflow options to fit your organization’s needs, including how to:
- Work a request in the inbox of your Attachments Dashboard.
- Enter and submit a web claim including supporting documentation.
- Use EDI batch options to trigger a request in your inbox.
- Track attachments you submitted using sent and history lists in your Attachments Dashboard.
- Get set up to use these tools.
As part of the session, we’ll answer questions and provide handouts and a job aid for you to reference later.
Register for an upcoming webinar session:
- In the Availity Portal, select Help & Training > Get Trained.
- The Availity Learning Center opens in a new browser tab.
- Search for and enroll in a session using one of these options:
- In the Catalog, search by webinar title or keyword.
- To find this specific live session quickly, use keyword medattach.
- Select the Sessions tab to scroll the live session calendar.
- After you enroll, you’ll receive emails with instructions to join the session.
Webinar Dates and Times (PST):
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January 8, 2021
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10:00 A.M. to 11:00 A.M.
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January 19, 2021
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12:00 P.M. to 1:00 P.M.
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Reduce the amount of time spent on transactional tasks by more than fifty percent when using our secure provider portal or EDI submissions (via Availity) to:
- File claims
- Check statuses
- Verify eligibility and benefits
- Submit prior authorizations
The Provider Digital Engagement Supplement outlines Empire BlueCross BlueShield’s (“Empire”) provider expectations, processes and self-service tools across all electronic channels, including medical, dental, and vision benefits - all in one comprehensive resource. Find it on empireblue.com> Providers> Forms & Guides> Digital Tools.
Through self-service functions, you can accomplish digital transactions all at one time, all in one place. If you are not already registered, visit empireblue.com and use the Log In button for access to our secure provider portal, or via the Availity EDI website.
Accept digital member ID cards
- Save time by accepting the digital member ID card when presented by the member via their App or email.
Register for EFT to get funds faster
- Electronic Funds Transfer (EFT) eliminate the need for paper checks. Safe, secure and faster, payments are deposited directly to your bank account. Register here.
Eliminate paper remittances
- Electronic remittance advice (ERA) is completely searchable and downloadable from the secure provider portal or the EDI 835 remittance. Meeting all HIPAA mandates, ERAs eliminate the need for paper remittances.
We appreciate your health care team going digital with Empire as of January 1, 2021, enabling us to realize our mutual goals of reducing administrative burden and increasing provider satisfaction and collaboration.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Introducing self-service claim denial review on our secure provider portal.
Empire BlueCross BlueShield (“Empire”) wants to make your job easier — and that includes real-time solutions to claim denials. Through predictive analytics, we now have insight into the reasons for claim denial. We have taken that information and streamlined claim denial inquiries by making those reasons available to you digitally, through our secure provider portal.
Now, within seconds, you will know why a claim denied. We will also provide the steps needed so you can take action faster to correct the claim - getting you paid faster.
No more calls for updates or any unnecessary delays waiting for the explanation of benefit.
With little more than a click:
- Review a complete list of claims, including claims with proactive insights
- Learn the reasons for claim denial
- Access the information you need to move the claimforward
Predictive analytics and self-service claim denial information is just another way Empire is using digital technology to improve your health care experience.
From empireblue.com, use the Log In button to access our secure provider portal Availity.com. Go to Payer Spaces to access Claims Status Listing.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Due to the ongoing pandemic and recent surge in COVID-19 cases, members are facing challenges with scheduling appointments for annual wellness visits and other medical services. As we have recently experienced, there has been a material increase in telehealth visits and the need to conveniently obtain routine health care. Our new digital online appointment scheduling feature would allow patients to proactively and safely schedule appointments with your office at the push of a button. Signing up is easy - there are no EMR integration requirements and can be completed in as little as thirty minutes!
If you would like to participate in our new online appointment scheduling capability, please send an email to recontracting@empireblue.com to learn more about how you can participate in this functionality.
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 Policies Effective 11-12-2020
(The following policies were revised to expand medical necessity indications or criteria.)
- GENE.00052 - Whole Genome Sequencing, Exome Sequencing, Gene Panels, and Molecular Profiling
- MED.00129 - Gene Therapy for Spinal Muscular Atrophy
Revised Medical Policy Effective 11-12-2020
(The following policy was reviewed and had no significant changes to the policy position or criteria.)
- ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin
Archived Medical Policy Effective 12-16-2020
(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)
- GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing [Note: Content transferred to CG-GENE-21 Cell-Free Fetal DNA-Based Prenatal Testing]
Revised Medical Policy Effective 12-16-2020
(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 12-16-2020
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ADMIN.00001 - Medical Policy Formation
- GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00016 - Gene Expression Profiling for Colorectal Cancer
- GENE.00025 - Proteogenomic Testing for the Evaluation of Malignancies
- 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
- MED.00002 - Selected Sleep Testing Services
- MED.00065 - Hepatic Activation Therapy
- 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.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
- MED.00130 - Surface Electromyography Devices for Seizure Monitoring
- RAD.00036 - MRI of the Breast
- RAD.00053 - Cervical and Thoracic Discography
- RAD.00065 - Radiostereometric Analysis
- REHAB.00003 - Hippotherapy
- SURG.00019 - Transmyocardial Revascularization
- SURG.00023 - Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures
- SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00036 - Fetal Surgery for Prenatally Diagnosed Malformations
- SURG.00037 - Treatment of Varicose Veins (Lower Extremity)
- SURG.00044 - Breast Ductal Examination and Fluid Cytology Analysis
- SURG.00073 - Epiduroscopy
- SURG.00079 - Nasal Valve Suspension
- SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents
- 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.00123 - Transmyocardial/ Perventricular Device Closure of a Ventricular Septal Defect
- SURG.00130 - Annulus Closure After Discectomy
- SURG.00138 - Laser Treatment of Onychomycosis
- SURG.00142 - Genicular Nerve Blocks and Ablation for Chronic Knee Pain
- SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
- SURG.00146 - Extracorporeal Carbon Dioxide Removal
- THER-RAD.00008 - Neutron Beam Radiotherapy
- 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.00033 - Heart Transplantation
- TRANS.00034 - Hematopoietic Stem Cell Transplantation for Diabetes Mellitus
Revised Medical Policies Effective 12-16-2020
(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
- MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00120 - Gene Therapy for Ocular Conditions
- SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
- SURG.00151 - Balloon Dilation of the Eustachian Tubes
- TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
New Medical Policies Effective 04-01-2021
(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.00055 - Gene Expression Profiling for Risk Stratification of Inflammatory Bowel Disease (IBD) Severity
- SURG.00158 - Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain [Note: Content addressing implantable devices (temporarily or permanently implanted) moved from DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices]
Revised Medical Policy Effective 04-01-2021
(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.)
- DME.00011 - Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices [Note: Content addressing implantable devices (temporarily or permanently implanted) moved to SURG.00158 - Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain]
New Medical Policy Effective 04-03-2021
(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.)
- LAB.00037 - Serologic Testing for Biomarkers of Irritable Bowel Syndrome (IBS)
Revised Medical Policy Effective 04-17-2021
(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.)
- SURG.00062 - Vein Embolization as a Treatment for Pelvic Congestion Syndrome and Varicocele
Clinical Guideline Updates
Revised Clinical Guidelines Effective 11-12-2020
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-GENE-14 - Gene Mutation Testing for Solid Tumor Cancer Susceptibility and Management
- CG-GENE-16 - BRCA Testing for Breast and/or Ovarian Cancer Syndrome
- CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
Revised Clinical Guideline Effective 11-12-2020
(The following adopted guideline was reviewed and had no significant changes to the policy position or criteria.)
- CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults
Revised Clinical Guidelines Effective 12-16-2020
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
- CG-GENE-18 - Genetic Testing for TP53 Mutations
- CG-GENE-20 - Epidermal Growth Factor Receptor (EGFR) Testing
Revised Clinical Guidelines Effective 12-16-2020
(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-ANC-07 - Inpatient Interfacility Transfers
- CG-BEH-14 - Intensive In-Home Behavioral Health Services
- CG-BEH-15 - Activity Therapy for Autism Spectrum Disorders and Rett Syndrome
- 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-GENE-12 - PIK3CA Mutation Testing for Malignant Conditions
- CG-GENE-15 - Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP), Attenuated FAP and MYH-associated Polyposis
- CG-GENE-17 - RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility
- CG-GENE-19 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
- 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-75 - Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions
- CG-SURG-77 - Refractive Surgery
- CG-SURG-92 - Paraesophageal Hernia Repair
- CG-SURG-94 - Keratoprosthesis
- CG-SURG-96 - Intraocular Telescope
- CG-SURG-105 - Corneal Collagen Cross-Linking
- CG-SURG-106 - Venous Angioplasty with or without Stent Placement or Venous Stenting Alone
Revised Clinical Guidelines Effective 12-16-2020
(The following adopted guidelines were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
- CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome
- CG-GENE-13 - Genetic Testing for Inherited Diseases
- CG-MED-66 - Cryopreservation of Oocytes or Ovarian Tissue
- CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
Revised Clinical Guideline Effective 01-16-2021
(The following adopted guideline was updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)
- CG-SURG-49 - Endovascular Techniques (Percutaneous or Open Exposure) for Arterial Revascularization of the Lower Extremities
Revised Clinical Guidelines Effective 04-17-2021
(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-SURG-71 - Reduction Mammoplasty
- CG-SURG-72 - Endothelial Keratoplasty
- CG-SURG-95 - Sacral Nerve Stimulation and Percutaneous Tibial Nerve Stimulation for Urinary and Fecal Incontinence; Urinary Retention
- CG-THER-RAD-07 - Intravascular Brachytherapy (Coronary and Noncoronary)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective April 1, 2021, the following new customizations will be implemented:
- Gastrointestinal Bleeding, Upper (W0170, previously ORG M-180) – Customized the Clinical Indications for admission to inpatient care by revising the hemoglobin; systolic blood pressure; pulse; melena; orthostatic hypotension; and BUN criteria.
- Gastrointestinal Bleeding, Upper Observation Care (W0171, previously OCG OC-021) – Customized the Clinical Indications for observation care by revising the systolic blood pressure and hemoglobin criteria and adding melena or hematochezia and suspected history of bleeding.
To view a detailed summary of customizations click on this link, scroll down to other criteria section and select Customizations to MCG Care Guidelines 24th Edition.
For questions, please contact the provider service number on the back of the member's ID card.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after April 1, 2021, Empire BlueCross BlueShield has updated our policy to reflect services must be reported with appropriate modifiers GN, GO and GP to identify therapy type.
For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield (“Empire”) recognizes all coding changes from both the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) effective the date provided by the coding source. This includes the Evaluation and Management (E/M) changes effective January 1, 2021.
The following updates pertaining to Evaluation and Management services have been identified:
- CPT code 99201 (new patient E/M) will be a deleted code.
- CPT codes 99202 through 99215 (new/established E/M) definitions have changed. Selection of these E/M codes can now be based on either Medical Decision Making or Time.
- CPT code 99417 (prolonged services) and HCPCS Code G2212 (prolonged services) will be recognized as billable codes. These codes will be payable based on our existing Prolonged Services policy, which will be updated to reflect the new code along with the modifications to existing prolonged service codes CPT codes 99354 and 99355.
- HCPCS Code G2211 (complexity inherent to evaluation and management associated with primary medical care) will not be separately reimbursed for this service. We will be updating our Bundled Services and Supplies policy to reflect this position.
Additionally, we are in the process of updating reimbursement policies impacted by the E/M service changes such as the Documentation and Reporting Guidelines for Evaluation and Management Services.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after April 1, 2021, Empire BlueCross BlueShield will update the related coding section of the policy to include new HCPCS codes (J9312, Q5103-Q5104 Q5107, Q5109, Q5115 Q5118-Q5119 and Q5121) and their billable units.
For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after April 1, 2021, Empire BlueCross BlueShield (“Empire”) has updated our Modifiers Impacting Adjudication to include GN, GO and GP to identify speech, occupational and physical therapy types and K0, K1, K2, K3 and K4 to be identify appropriate functional level.
For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after April 1, 2021, Empire BlueCross BlueShield has updated our policy to reflect that constant attendance, timed modalities for physical therapy, occupational therapy or speech therapy are limited to 4 Units or 1 hour per date of service for the same member, by the same provider, per therapy type for (97110 – 97124, 97129, 97130, 97140, 97533 – 97542, 97760 – 97763).
Additionally, the policy was updated to remove deleted codes 99363, 99364 and J9031 and add the following codes, effective January 1, 2020: 96158, 96164, 92273, 92274, 93792, 93973 and J9030.
For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after April 1, 2021, Empire BlueCross BlueShield policy language has been updated to apply a five percent multiple imaging reduction to the professional component of diagnostic imaging procedures that have a Multiple Procedure Indicator (MPI) of 4.
For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. To view the 2021 benefits and changes for the Blue Cross Blue Shield Service Benefit Plan, also known as the Federal Employee Program® (FEP), go to www.fepblue.org>select Tools & Resources>Brochure & Resources>Plan Brochures. Here you will find the Service Benefit Plan Brochure and Benefit Plan Summary information for year 2021. For questions please contact FEP Customer Service at 1-800-522-5566.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Starting January 1, 2021, IngenioRx, the pharmacy benefit manager for our affiliated health plans, will make its new standard pharmacy network available to your patients. The standard network will be made up of about 58,000 pharmacies nationwide, including well-known national chains like Costco, CVS, Kroger, Sam’s Club, Target and Walmart.
With robust access, your patients can use any participating pharmacy across the country in the standard network to fill their prescriptions.
Network Notification Plan
Some of your patients covered by an Empire BlueCross BlueShield (“Empire”) health plan may currently use pharmacies that are not in this new network. They’ll need to transfer their active prescription(s) to a network pharmacy to ensure there is no interruption of their coverage.
Prior to the network effective date, we’ll notify your patients by letter outlining the easy steps about transferring their prescriptions to another pharmacy in the network.
In addition, to help you easily send prescriptions to a participating pharmacy, upon the member’s effective date, we’ll include messaging via your patients’ electronic medical record. This message will appear if you attempt to submit a prescription to a pharmacy that’s not included in the standard network. This will ensure your patients’ prescriptions are properly routed to a network pharmacy and will help them continue to receive their medications worry-free.
If your patients would like to search for a network pharmacy prior to the new network effective date, they can log in to empireblue.com, where instructions will appear with a helpful link to our online pharmacy search tool. They can enter their address/city/state or their zip code to begin searching.
Questions?
Please refer to our helpful Frequently Asked Questions for more details about the new standard network.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. 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.
The following Clinical Criteria documents were endorsed at the November 20, 2020 Clinical Criteria meeting. To access the clinical criteria information please click here.
Revised Clinical Criteria effective December 3, 2020
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0119 - Yervoy (ipilimumab)
- ING-CC-0125 - Opdivo (nivolumab)
Revised Clinical Criteria effective December 9, 2020
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0011 - Ocrevus (ocrelizumab)
- ING-CC-0174 - Kesimpta (ofatumumab)
Revised Clinical Criteria effective December 21, 2020
The following current clinical criteria were revised to expand medical necessity indications or criteria.
- ING-CC-0003 – Immunoglobulins
- ING-CC-0034 - Hereditary Angioedema Agents
- ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
- ING-CC-0062 - Tumor Necrosis Factor Antagonists
- ING-CC-0063 - Stelara (ustekinumab)
- ING-CC-0065 - Agents for Hemophilia A and von Willebrand Disease
- ING-CC-0072 - Selective Vascular Endothelial Growth Factor (VEGF) Antagonists
- ING-CC-0075 - Rituximab Agents for Non-Oncologic Indications
- ING-CC-0121 - Gazyva (obinutuzumab)
- ING-CC-0148 - Agents for Hemophilia B
- ING-CC-0149 - Select Clotting Agents for Bleeding Disorders
Revised Clinical Criteria effective December 21, 2020
The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0006 - Hyaluronan Injections
- 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-0107 - Bevacizumab for Non-Ophthalmologic Indications
- ING-CC-0133 - Aliqopa (copanlisib)
- ING-CC-0150 - Kymriah (tisagenlecleucel)
- ING-CC-0151 - Yescarta (axicabtagene ciloleucel)
- ING-CC-0155 - Ethyol (amifostine)
- ING-CC-0166 - Trastuzumab Agents Step Therapy
- ING-CC-0167 - Rituximab Agents for Oncologic Indications Step Therapy
- ING-CC-0173 - Enspryng (satralizumab-mwge)
Revised Clinical Criteria effective January 1, 2021
The following clinical criteria was reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0001 - Erythropoiesis Stimulating Agents
Revised Clinical Criteria effective February 1, 2021
The following clinical criteria was reviewed with no significant change to the medical necessity indications or criteria.
- ING-CC-0014 - Beta Interferons and Glatiramer Acetate for Treatment of Multiple Sclerosis
New Clinical Criteria effective April 1, 2021
The following clinical criteria is new.
- ING-CC-0183 Sogroya (somapacitan-beco)
Revised Clinical Criteria effective April 1, 2021
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-0011 - Ocrevus (ocrelizumab)
- ING-CC-0027 - Denosumab Agents
- ING-CC-0034 - Hereditary Angioedema Agents
- ING-CC-0039 - GamaSTAN [immune globulin (human)]
- ING-CC-0041 - Complement Inhibitors
- ING-CC-0042 - Monoclonal Antibodies to Interleukin-17
- 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-0066 - Monoclonal Antibodies to Interleukin-6
- ING-CC-0071 - Entyvio (vedolizumab)
- ING-CC-0073 - Alpha-1 Proteinase Inhibitor Therapy
- ING-CC-0078 - Orencia (abatacept)
- ING-CC-0121 - Gazyva (obinutuzumab)
- ING-CC-0148 - Agents for Hemophilia B
- ING-CC-0149 - Select Clotting Agents for Bleeding Disorders
- ING-CC-0174 - Kesimpta (ofatumumab)
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Prior authorization updates
Effective for dates of service on and after April 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
To access the Clinical Criteria information please click here.
Empire BlueCross BlueShield’s (“Empire”) prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
|
Clinical Criteria
|
HCPCS or CPT Code(s)
|
Drug
|
|
*ING-CC-0095
|
J9041
|
Velcade (Bortezomib)
|
|
*ING-CC-0095
|
J9044
|
Bortezomib
|
|
*ING-CC-0093
|
J9171
|
Docetaxel
|
|
*ING-CC-0181
|
J3490
|
Veklury
|
Step therapy updates
Update on Ocrevus Step Therapy Notification
Ocrevus will still be non-preferred as noted below, but please note that the step therapy criteria have been updated since the last publication.
Effective for dates of service on and after February 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our existing specialty pharmacy medical step therapy review process.
To access the step therapy drug list, please click here.
Empire’s prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology indications will be managed by AIM Specialty Health® (AIM), a separate company and are shown in italics in the table below.
|
Clinical Criteria
|
Status
|
Drug(s)
|
HCPCS Codes
|
|
ING-CC-0011
|
Non-preferred
|
Ocrevus
|
J2350
|
Correction to a prior authorization update
In the November 2020 edition of Provider News, we published a correction to an article originally published in the October 2020 Provider News regarding clinical criteria ING-CC-0174 for the drug Kesimpta. Please disregard the November update and refer to the original article published in October 2020 for the correct HCPCS codes. For your convenience, we’ve also listed the correct HCPCS codes for Kesimpta below.
- NOC codes J3490, J3590 and C9399 are valid codes for Kesimpta. Code J9302 is not a valid code for the drug Kesimpta.
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. The Medicare Risk Adjustment Regulatory Compliance team at Empire BlueCross BlueShield offers two provider training programs regarding Medicare risk adjustment and documentation guidelines. Information for each training is outlined below.
Medicare risk adjustment and documentation guidance (General):
- Series: Offered the first Wednesday of each month from 1:00 to 2:00 P.M. (ET)*
- Learning objective: This onboarding training will provide an overview of Medicare risk adjustment, including the risk adjustment factor and the hierarchical condition category (HCC) model, with guidance on medical record documentation and coding.
- Credits: This live activity, Medicare risk adjustment and documentation guidance, from
January 8, 2020 to December 2, 2020, has been reviewed and is acceptable for up to 1.00 prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
To learn how providers play a critical role in facilitating the risk adjustment process, register for one of the monthly training sessions at the link below:
https://bit.ly/2TYMgbn
* Note: Dates may be modified due to holiday scheduling
Medicare risk adjustment, documentation and coding guidance (Condition specific)
- Series: Offered the third Wednesday of each month from 1:00 to 2:00 P.M. (ET)
- Learning objective: This training series will provide in-depth disease information pertaining to specific conditions, including an overview of their corresponding hierarchical condition categories (HCC), with guidance on documentation and coding.
- Credits: This live series activity, Medicare risk adjustment documentation and coding guidance, from January 15, 2020 to November 18, 2020, has been reviewed and is acceptable for credit by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity
For those interested in the following training topics, please register at the link below.
https://bit.ly/2IgxDO9
* Note: Enter the password provided, and the recording will play upon registration.
- Red flag HCCs
- Neoplasms
- Acute, chronic and status conditions
- Diabetes mellitus and other metabolic disorders
- Coinciding conditions in risk adjustment models
Please note that the original training events have been modified due to a transition within WebEx as of August 1, 2020. The date and time of the events have not changed but the program link and invitation detail have been updated. Previously registered participants will need to re-register for a training event using the updated registration link(s) provided in this announcement.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the [Clinical Criteria Web Posting August 2020]. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).
The following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging for claims with dates of service on and after March 14, 2021.
Chest imaging, and head and neck imaging
Hoarseness, dysphonia and vocal cord weakness/paralysis — primary voice complaint:
- Required laryngoscopy for the initial evaluation of all patients with primary voice complaint
Brain imaging, and head and neck imaging
Hearing loss:
- Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed
- Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss
- Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance
Tinnitus:
- Removed sudden onset symmetric tinnitus as an indication for advanced imaging
Head and neck imaging
Sinusitis/rhinosinusitis:
- Added more flexibility for the method of conservative treatment in chronic sinusitis
- Required conservative management prior to repeat imaging for patients with prior sinus CT
Temporomandibular joint dysfunction:
- Removed requirement for radiographs/ultrasound
Cerebrospinal fluid (CSF) leak of the skull base:
- Added scenario for management of known leak with change in clinical condition
Brain imaging
Ataxia, congenital or hereditary:
- Combined with congenital cerebral anomalies to create one section
Acoustic neuroma:
- More frequent imaging for a watch and wait or incomplete resection
- New indication for neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2
- More frequent imaging when MRI shows findings suspicious for recurrence
- Single post-operative MRI following gross total resection
- Included pediatrics with known acoustics (rare but NF 2)
Tumor — not otherwise specified:
- Repurposed for surveillance imaging of low grade neoplasms
Seizure disorder and epilepsy:
- Limited imaging for the management of established generalized epilepsy
- Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy
Headache:
- Removed response to treatment as a primary headache red flag
- Include pregnancy as a red flag risk factor
Mental status change and encephalopathy:
- Added requirement for initial clinical and lab evaluation to assess for a more specific cause
Oncologic imaging
General enhancements — Updates to Scope/Definitions, general language standardization
General content enhancements — Overall alignment with current National Comprehensive Cancer Network (NCCN) recommendations, resulting in:
- Removal of indications/parameters not addressed by NCCN
- Average risk inclusion criteria for CT colonography
- New allowances for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
- New indications for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
- Updated standard imaging prerequisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, esophageal/GE junction, gastric and non-small cell lung cancers
- Additional PET/CT management scenarios for cervical cancer, Hodgkin Lymphoma
Other content enhancements by section
Cancer screening: New indication for pancreatic cancer screening
Breast cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy
Prostate cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE
Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM Specialty Health (AIM) in one of several ways:
- Access the AIM ProviderPortalSM directly at https://aimspecialtyhealth.com/providerportal.
- Online access is available 24/7 to process orders and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity* Portal at https://availity.com.
- Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. CT.
If you have questions related to guidelines, please contact AIM by 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. Keep up with Medicaid news
Please continue to check Medicaid Provider Communications & updates at www.empireblue.com/nymedicaiddoc for the latest Medicaid information, including:
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Disease Management/Population Health is designed to support providers in caring for patients with chronic health care needs. Empire BlueCross BlueShield HealthPlus (Empire) provides members enrolled in the program with continuous education on self-management, assistance in connecting to community resources, and coordination of care by a team of highly qualified professionals whose goal is to create a system of seamless health care interventions and communications.
Who is eligible?
Disease Management/Population Health case managers provide support to members with:
- Asthma
- Bipolar disorder
- COPD
- Diabetes
- Congestive heart failure
- Coronary artery disease
- HIV/AIDS
- Hypertension
- Major depressive disorder — adults
- Major depressive disorder — children and adolescents
- Schizophrenia
- Substance use disorder
Our case managers use member-centric motivational interviewing to identify and address health risks, such as tobacco use and obesity, to improve condition-specific outcomes. Interventions are rooted in evidence-based clinical practice guidelines from recognized sources. We implement continuous improvement strategies to increase evaluation, management and health outcomes.
For more information on our program and how to refer an Empire member for this program, please visit our website at www.empireblue.com/nymedicaiddoc.
Your input and partnership is valued. Once your patient is enrolled in the Disease Management/Population Health program, you will be notified by the case manager assigned.
We look forward to working with you.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. HEDIS overview
The National Committee for Quality Assurance (NCQA) is a non-profit organization that accredits and certifies health care organizations. The NCQA establishes and maintains the Healthcare Effectiveness Data and Information Set (HEDIS®). HEDIS is a tool comprised of standardized performance measures used to compare managed care plans. The overall goal is to measure the value of health care based on compliance with HEDIS measures. HEDIS also allows stakeholders to evaluate physicians based on health care value rather than cost. This article will outline specific changes to the HEDIS measures as outlined by the NCQA. The changes are effective for the measurement year (MY) 2020 to 2021. It is important to note that the state health agency has the authority to determine which measures and rates managed care organizations should capture.
HEDIS data helps calculate national performance statistics and benchmarks and sets standards for measures in NCQA Accreditation.
Health plans use HEDIS performance results to:
- Evaluate the quality of care and services.
- Evaluate provider performance.
- Develop performance improvement initiatives.
- Perform outreach to providers and members.
- Compare performance with other health plans.
HEDIS MY 2020 new measures:
- Follow-up After High-Intensity Care for Substance Use Disorder (FUI)
- Pharmacotherapy for Opioid Use Disorder (POD)
- Breast Cancer Screening (BCS-E)
- Follow-up Care for Children Prescribed ADHD Medication (ADD-E)
- Prenatal Depression Screening and Follow-up (PND)
- Postpartum Depression Screening and Follow-up (PDS)
HEDIS MY 2020 retired measures:
- Annual Monitoring for Patients on Persistent Medications (MPM)
- Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC)
- Standardized Healthcare-Associated Infection Ratio (HAI).
Retired measures are no longer maintained by NCQA or included in the HEDIS measurement set. NCQA has determined that specific measures are clinically inappropriate and are no longer in use. Once retired, the measures are not used in any product, program or service, and all use must stop.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On August 21, 2020, the Pharmacy and Therapeutics (P&T) Committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus. These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the provider websites, and the effective dates will be reflected in the Clinical Criteria Web Posting August 2020. Visit Clinical Criteria to search for specific policies.
If you have questions or would like additional information, use this email.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield HealthPlus (Empire) reviews the activities of the Food and Drug Administration (FDA)’s approval of drugs and biologics on a regular basis to understand the potential effects for our providers and members.
The FDA approves new drugs and biologics using various pathways. Recent studies on the effectiveness of drugs and biologics going through different FDA pathways illustrates the importance of clinicians being aware of the clinical data behind a drug or biologic approval in making informed decisions.
Here is a list of the approval pathways the FDA uses for drugs/biologics:
- Standard review — The standard review process follows well-established paths to make sure drugs/biologics are safe and effective when they reach the public. From concept to approval and beyond, FDA performs these steps: reviews research data and information about drugs and biologics before they become available to the public; watches for problems once drugs and biologics are available to the public; monitors drug/biologic information and advertising; and protects drug/biologic quality. Follow this link to learn more about the standard review process.
- Fast track — Fast track is a process designed to facilitate the development and expedite the review of drugs/biologics to treat serious conditions and fill an unmet medical need. Follow this link to learn more about the fast track process.
- Priority review —A priority review designation means FDA’s goal is to take action on an application within six months. Follow this link to learn more about the priority review process.
- Breakthrough therapy — This process is designed to expedite the development and review of drugs/biologics which may demonstrate substantial improvement over available therapy. Follow this link to learn more about the breakthrough therapy review process.
- Orphan review — This refers to the review of drugs that demonstrate promise for the diagnosis and/or treatment of rare diseases or conditions. Follow this link to learn more about the orphan drug review process.
- Accelerated approval — These regulations allowed drugs/biologics for serious conditions that filled an unmet medical need to be approved based on a surrogate endpoint. To learn more about the accelerated approval process, follow this link.
New molecular entities approvals: January 2020 through August 2020
Certain drugs/biologics are classified as new molecular entities (NMEs) for purposes of FDA review. Many of these products contain active ingredients that have not been approved by FDA previously, either as a single ingredient drug or as part of a combination product; these products frequently provide important new therapies for patients.
Empire reviews the FDA-approved NMEs on a regular basis. To facilitate the decision-making process, we are providing the attached list of NMEs approved from January to August 2020 along with the FDA approval pathway utilized.
Note: This information has no impact on our standard prior authorization/pre-certification process.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Medicaid and Medicare Advantage programs for Empire BlueCross BlueShield (Empire).
The following updates will apply to the AIM Clinical Appropriateness Guidelines for Advanced Imaging for claims with dates of service on and after March 14, 2021.
Chest imaging, and head and neck imaging
Hoarseness, dysphonia and vocal cord weakness/paralysis — primary voice complaint:
- Required laryngoscopy for the initial evaluation of all patients with primary voice complaint
Brain imaging, and head and neck imaging
Hearing loss:
- Added CT temporal bone for evaluation of sensorineural hearing loss in any pediatric patients or in adults for whom MRI is non-diagnostic or unable to be performed
- Higher allowed threshold for consecutive frequencies to establish sensorineural hearing loss
- Removed CT brain as an alternative to evaluating hearing loss based on ACR guidance
Tinnitus:
- Removed sudden onset symmetric tinnitus as an indication for advanced imaging
Head and neck imaging
Sinusitis/rhinosinusitis:
- Added more flexibility for the method of conservative treatment in chronic sinusitis
- Required conservative management prior to repeat imaging for patients with prior sinus CT
Temporomandibular joint dysfunction:
- Removed requirement for radiographs/ultrasound
Cerebrospinal fluid (CSF) leak of the skull base:
- Added scenario for management of known leak with change in clinical condition
Brain imaging
Ataxia, congenital or hereditary:
- Combined with congenital cerebral anomalies to create one section
Acoustic neuroma:
- More frequent imaging for a watch and wait or incomplete resection
- New indication for neurofibromatosis type 2 (NF 2)Neurofibromatosis type 2
- More frequent imaging when MRI shows findings suspicious for recurrence
- Single post-operative MRI following gross total resection
- Included pediatrics with known acoustics (rare but NF 2)
Tumor — not otherwise specified:
- Repurposed for surveillance imaging of low grade neoplasms
Seizure disorder and epilepsy:
- Limited imaging for the management of established generalized epilepsy
- Required optimal medical management (aligning adult and pediatric language) prior to imaging for management in epilepsy
Headache:
- Removed response to treatment as a primary headache red flag
- Include pregnancy as a red flag risk factor
Mental status change and encephalopathy:
- Added requirement for initial clinical and lab evaluation to assess for a more specific cause
Oncologic imaging
General enhancements — Updates to Scope/Definitions, general language standardization
General content enhancements — Overall alignment with current National Comprehensive Cancer Network (NCCN) recommendations, resulting in:
- Removal of indications/parameters not addressed by NCCN
- Average risk inclusion criteria for CT colonography
- New allowances for MRI abdomen and/or MRI pelvis by tumor type, liver metastatic disease
- New indications for acute leukemia (CT, PET/CT), multiple myeloma (MRI, PET/CT), ovarian cancer surveillance (CT), bone sarcoma (PET/CT)
- Updated standard imaging prerequisites prior to PET/CT for bladder/renal pelvis/ureter, ectal, esophageal/GE junction, gastric and non-small cell lung cancers
- Additional PET/CT management scenarios for cervical cancer, Hodgkin Lymphoma
Other content enhancements by section
Cancer screening: New indication for pancreatic cancer screening
Breast cancer: New PET/CT indication for restaging/treatment response for bone-only metastatic disease and limitation of post-treatment breast MRI after breast conserving therapy or unilateral mastectomy
Prostate cancer: MRI pelvis: removal of TRUS biopsy requirement, allowance if persistent/unexplained elevation in PSA or suspicious DRE
Axumin PET/CT: Updated inclusion criteria (removal of general MRI pelvis requirement, additional allowance for rising PSA with non-diagnostic mpMRI)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM Specialty Health (AIM) in one of several ways:
- Access the AIM ProviderPortalSM directly at https://aimspecialtyhealth.com/providerportal.
- Online access is available 24/7 to process orders and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity* Portal at https://availity.com.
- Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. CT.
If you have questions related to guidelines, please contact AIM by email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
|