As previously communicated in the December 2022 edition of Provider News,AIM Specialty Health_® (AIM)* will apply additional code updates to the AIM Diagnostic Coronary Angiography and Percutaneous Coronary Intervention Clinical Appropriateness Guidelines. That code update expansion has been delayed. The codes listed below will go into effect April 1, 2023, not February 1, 2023, as originally communicated.

Percutaneous coronary intervention:

• Access AIM’s ProviderPortal_SM 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.
• Call the AIM Contact Center toll-free number at 800-714-0040, Monday through Friday, from 7 a.m. to 7 p.m. Central

If you have questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_® (AIM)* Musculoskeletal — Interventional Pain Management Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Interventional pain management — updates by section:

• Epidural steroid injections:
  • For nerve root compression due to herniated disc, specified that the MRI/CT showing this finding must have been done within 18 months instead of 12 months.
• Selective nerve root block:
  • Included a second session for cases requiring evaluation of more than one level.
• Therapeutic intra-articular facet injections:
  • Included criteria for repeat injections in patients who met criteria for an initial injection.
• Conservative management requirements:
  • Aligned definitions with joint surgery, spine surgery, spine, and extremity imaging guidelines.
  • More rigorous definition of the supervised home physical therapy requirement and removed cognitive behavioral therapy as a conservative care modality.
  • Included activity modification and a trial of rest.
• Epidural steroid injections:
  • Specified that only one spinal region may be treated per date of service.
  • For repeat injection, prior injection must have provided improvement for three months instead of three weeks.
• Diagnostic medial branch block:
  • Specified that up to four diagnostic sessions may be done in a rolling 12-month period (previously three).
  • Reduced the number of unilateral levels that may be done in a session from three to two.
• Thermal medial branch radiofrequency neurotomy:
  • Reduced the number of unilateral levels that may be done in a session from three to two.
  • Specified a maximum of two radiofrequency sessions per rolling 12-month period.
• Regional sympathetic nerve block:
  • Specified that procedure must be performed using imaging guidance.
  • Specified that the procedure must be performed unilaterally.
  • Specified a lifetime maximum of six blocks.
  • Removed exclusions that referred to procedures which are no longer performed.
• Through AIM’s ProviderPortal_SM 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.

If you have 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 online.

Background

Providers are a trusted resource for patients when it comes to vaccine advice. As information on the monkeypox outbreak changes and vaccination and testing guidance is released, we’re committed to keeping you informed.

Some providers may have seen a message on their provider Explanation of Payment (EOP) stating that Empire BlueCross BlueShield HealthPlus does not recognize the vaccine product codes for monkeypox and smallpox that became effective July 26, 2022. We’re updating the provider fee schedules to reflect the new vaccine product codes as quickly as possible. The EOP message did not impact payment for administration of the vaccines, which is reimbursable; however, since the monkeypox and smallpox vaccines are provided by the government at no charge, the vaccine products are non-reimbursable.

To aid in processing claims for the monkeypox and smallpox vaccine products, providers must include these three elements on claims, even if vaccine products were received from the federal government at no charge:

1. Product code (90611 or 90622)
2. Applicable ICD-10-CM diagnosis code
3. Administration code

More detail on codes and cost-sharing

Providers are encouraged to use:

• Product code 90611 for smallpox and monkeypox vaccine.
• Product code 90622 for vaccinia (smallpox) virus vaccine.
• Code 87593 for laboratory testing.

When billing the monkeypox and smallpox vaccine products, providers should submit those codes with a $0.01 charge.

Cost-sharing for the vaccine and administration is waived.

What if I need assistance?

If you have questions about this communication or need assistance with any other item, contact your assigned Provider Experience associate or call Provider Services at 800-450-8753. You can read more information on monkeypox here.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Updates by guideline

• Imaging of the Brain:
  • Meningioma — Added more frequent surveillance for WHO grade II/III
  • Bell’s palsy — Limited the use of CT to scenarios where MRI cannot be performed
  • Seizure disorder — Added indication for advanced imaging in pediatric patients with nondiagnostic electroencephalogram (EEG)
• Imaging of the Head and Neck:
  • Perioperative imaging — Added indication for imaging prior to facial feminization surgery
• Imaging of the Chest:
  • Perioperative imaging — Added indication for imaging prior to lung volume reduction procedures
  • Imaging abnormalities — Added indication for evaluation of suspected tracheal or bronchial pathology
• Imaging of the Abdomen/Pelvis:
  • Uterine leiomyomata — Added indication for advanced imaging when ultrasound suggests leiomyosarcoma
  • Pancreatic indications — Added indication for pancreatic duct dilatation
  • Pancreatic mass — Added allowance for more frequent follow up of lesions with suspicious features or in high-risk patients
  • Pancreatitis — Removed allowance for MRI following nondiagnostic CT
  • Pelvic floor disorders — Added indication for MRI pelvis in chronic constipation when preliminary testing is nondiagnostic
  • Abdominal/pelvic pain, undifferentiated — Removed indication for MRI following nondiagnostic CT
• Oncologic Imaging:
  • National Comprehensive Cancer Network annual alignments for breast cancer screening and the following: Cervical, Head and Neck, Histiocytic Neoplasms, Lymphoma (Non-Hodgkin and Leukemia), Multiple Myeloma, Thoracic, and Thyroid cancers
  • Prostate Cancer:
    • Updated respective conventional imaging prerequisites for 18F Fluciclovine/11C PET/CT and 68Ga PSMA/18F-DCFPyL PET/CT, based on utility of conventional imaging at various PSA thresholds (and removal of low-risk disease waiver from conventional imaging footnote).
    • Addition of 68Ga PSMA or 18F-DCFPyL PET/CT indication aligned with FDA-approved use of Pluvicto (radioligand) treatment for metastatic castrate-resistant disease

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM by accessing AIM’s ProviderPortal_SM directly at www.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.

For questions related to guidelines, contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* (AIM) Radiation Oncology Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

• Radiation Therapy— Updates by section
  • Gastrointestinal (GI) Cancers — Intensity modulated radiation therapy (IMRT)
  • Removed plan comparison requirement for cholangiocarcinoma, esophageal, gastric, hepatocellular, and pancreatic cancer, because IMRT has become standard of care for curative treatment of these GI malignancies
• Oligometastatic Extracranial Disease— SBRT: stereotactic body radiation therapy (SBRT)
  • Added indication for adrenal metastases as SABR-COMET trial listed this as one of the most common sites treated in that trial
• Prostate Cancer— Brachytherapy:
  • Added indication for high-dose rate monotherapy in low- and intermediate-risk disease
• Image Guidance radiation therapy (IGRT)
  • Added surface-based guidance technique (no change in intent or coding)
  • Added statement that IGRT is not medically necessary to guide superficial radiotherapy for non-melanoma skin cancer (supported by American Society for Radiation Oncology [ASTRO] Clinical Practice Guideline)

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM through the AIM ProviderPortal_SM directly at www.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.

For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you can access and download a copy of the current and upcoming guidelines here.

Effective for dates of service on and after April 9, 2023, the following updates will apply to the AIM Specialty Health_®* Cardiology Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate and affordable healthcare services.

Cardiac Imaging — Updates by section

Stress testing with imaging:

• Suspected coronary artery disease (CAD) without symptoms — Indications removed
• Suspected CAD with symptoms — Indications modified
• Need for testing determined by pretest probability
• Definition of chest pain expanded to include ischemic equivalent pain elsewhere
• Dyspnea included as standalone symptom
• Imaging modality to be selected by the treating physician
• Exercise preferred over pharmacologic testing in patients referred for stress testing with imaging
• Patients with atypical symptoms to undergo non-imaging stress testing (assuming capable of exercise and no precluding resting EKG abnormalities)
• Established CAD without symptoms — Indications removed
• Established CAD with symptoms — Indications removed

CT coronary angiography (CCTA):

• Indications added — Considerable expansion in use for evaluation of CAD (now a first-line modality)
• Indications added — Preoperative testing indications
• Indications added — Abnormal prior testing indications
• Indications removed — Suspected anomalous coronary arteries (basis for suspicion required)

Fractional Flow Reserve from CCTA (FFR-CT):

• Indication modified — 40% to 90% coronary stenosis in symptomatic patient who has failed guideline-directed medical therapy and has undergone CCTA within preceding 90 days

Stress Cardiac MRI:

• Indications added — Considerable expansion in use for evaluation of CAD (now a first-line modality)
• Indications added — Preoperative testing indications
• Indications added — Abnormal prior testing indications

Resting Cardiac MRI:

• Indication added — Fabry disease
• Indications modified — Suspected myocarditis (basis for suspicion required)
• Indications modified — Arrhythmogenic right ventricular dysplasia (ARVD) requirements clarified
• Indications modified — Suspected anomalous coronary arteries (basis for suspicion required)

Resting transthoracic echocardiography (TTE):

• Valvular heart disease — updated frequency of surveillance in patients with prosthetic valves and those who had transcatheter valve replacement/repair; removed requirement of valvular dysfunction for those who had surgical mitral valve repair; removed moderate/severe mitral regurgitation for those who had transcatheter mitral valve repair

Diagnostic Coronary Angiography:

• Indications modified — Clarification that patients with established CAD who have failed GDMT may undergo coronary angiography regardless of how initial diagnosis was made

As a reminder, ordering and servicing providers may submit prior authorization requests to AIM by accessing AIM’s ProviderPortal_SM directly at www.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.

If you have 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.

These updates list the new and/or revised Medical Policies and Clinical Guidelines for Empire BlueCross BlueShield (Empire). The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised Medical Policy or Clinical Guidelines 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. Include this update with your provider manual for future reference.

Note that Medical Policy, which addresses medical efficacy, should be considered before using medical opinion in adjudication. Empire’s Medical Policy and Clinical Guidelines can be found at https://www.empireblue.com.

Note: These updates may not apply to all administrative services only (ASO) accounts as some accounts may have nonstandard benefits that apply.

To view Medical Policies and Clinical Utilization Management (UM) Guidelines applicable to members enrolled in the Blue Cross and Blue Shield service benefit plan (commonly referred to as the Federal Employee Program FEP^®), please visit www.fepblue.org > Policies & Guidelines.

Medical Policy updates

Archived medical policies effective April 1, 2023

The following policies have been archived:

• 00033 Genetic Testing for Inherited Peripheral Neuropathies (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases)
• 00037 Genetic Testing for Macular Degeneration (Note: Content merged into GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling and CG-GENE-13 Genetic Testing for Inherited Diseases.)
• 00038 Genetic Testing for Statin-Induced Myopathy (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases.)
• 00039 Genetic Testing for Frontotemporal Dementia (FTD) (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases)

Revised medical policy effective April 1, 2023

This 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:

• 00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling (Note: Moved content from GENE.00037 Genetic Testing for Macular Degeneration and CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions into this document.)

Clinical Guidelines updates

Archived clinical guidelines effective April 1, 2023

The following clinical guidelines have been archived:

• CG-GENE-07 BCR-ABL Mutation Analysis (Note: Content merged into CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.)
• CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility (Content merged into CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management.)
• CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions (Note: Content merged into CG-GENE-13 Genetic Testing for Inherited Diseases and GENE.00052 Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling.)

Revised clinical guidelines effective April 1, 2023

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-GENE-13 Genetic Testing for Inherited Diseases (Note: Moved content from CG-GENE-23 Genetic Testing for Heritable Cardiac Conditions, GENE.00033 Genetic Testing for Inherited Peripheral Neuropathies, GENE.00037 Genetic Testing for Macular Degeneration (partial content), GENE.00038 Genetic Testing for Statin-induced Myopathy, and GENE.00039 Genetic Testing for Frontotemporal Dementia (FTD) into this document.)
• CG-GENE-14 Gene Mutation Testing for Cancer Susceptibility and Management (Note: Moved content from CG-GENE-07 BCR-ABL Mutation Analysis and CG-GENE-17 RET Proto-oncogene Testing for Endocrine Gland Cancer Susceptibility into this document.)

Material Adverse Change (MAC)

This communication applies to Commercial and Medicare Advantage plans from Empire BlueCross BlueShield (Empire).

Beginning with dates of service on or after April 1, 2023, or the end of the public health emergency (PHE), whichever is later, reimbursement for COVID-19 laboratory service codes may be reduced for participating providers contracted with Empire.

New COVID-19 laboratory service codes were implemented and reimbursed at rates to meet the needs of providers during the PHE. Reimbursement will now be revised to Empire's standard reimbursement methodology for the following codes:

If you have any questions regarding this notice, please contact Provider Services or use Availity* Live Chat, which is available during normal business hours. Go to www.availity.com and select Empire from the payer spaces drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

Effective with dates of service on or after April 1, 2023, the Federal Employee Program^® (FEP) with Empire BlueCross BlueShield (Empire) will refer the following procedures for observation stay instead of full inpatient admission. These services will require prior authorization to determine medical necessity prior to rendering the service for Empire federal employee members. 

For services that are scheduled to begin on or after April 1, 2023, all providers must be aware that for the following procedures, FEP will be approving observation stay versus inpatient stay when medically appropriate:

• Knee arthroplasty (total/partial/revision knee)
• Shoulder arthroplasty (hemi arthroplasty/arthroscopy) 
• Hip arthroplasty (total/partial/revision hip replacement) and hip arthroscopy
• Cervical fusion (anterior)
• Cervical discectomy or microdiscectomy, foraminotomy, and laminotomy
• Lumbar discectomy, foraminotomy, and/or laminotomy
• Small joint surgeries of the foot and ankle 
• Reconstruction midface, LeFort I-III
• Sacral-Iliac fusion 

How to submit a request for review

Starting March 13, 2023, providers can begin submitting requests for review with dates of service on or after April 1, 2023.  

To reach the FEP Utilization Management (UM) department to submit an authorization request, providers may call our department directly, fax a request, or submit a request via Availity Essentials* with clinical information:

• Phone number:800-860-2156
• Fax:800-732-8318
• Chat: To chat with an FEP UM representative, go to: availity.com. Select Payer Spaces, select Federal Employee Plan, and access the chat through Chat with Payer.

We value your participation in our network, as well as the services you provide. We look forward to working with you to help improve the health of our members. 

The Medical Specialty Drug Review team for Empire BlueCross BlueShield manages prior authorization clinical review of non-oncology use of specialty pharmacy drugs. AIM Specialty Health_®* (AIM), a separate company, manages review of specialty pharmacy drugs for oncology.

Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.

Including the national drug code (NDC) code on your claim may help expedite claim processing of drugs billed with a not otherwise classified (NOC) code.

Clinical Criteria update: Effective January 1, 2023, clinical criteria naming will be changed
from ING-CC-XXXX to CC-XXXX; however, the content within the documents will remain unchanged.

Prior authorization updates

Correction: In the August 2022 edition of Provider News, we published prior authorization updates for the drug Pluvicto (lutetium lu 177 vipivotide tetraxetan). Please be advised that the effective date for this update has been changed:

• Previous effective date: November 1, 2022
• Updated effective date: February 1, 2023

Access our Clinical Criteria to view the complete information for these prior authorization updates.

* Oncology use is managed by AIM.