July 2021 Newsletter

Contents

AdministrativeCommercialJune 30, 2021

Surgical Clinical Site of Care review updates

AdministrativeCommercialJune 30, 2021

Another mark of the pandemic: an increase in childhood obesity

AdministrativeCommercialJune 30, 2021

Commercial Repapering: Important update

Digital SolutionsCommercialJune 30, 2021

How to enroll in electronic fund transfer (EFT) for faster remittance

Digital SolutionsCommercialJune 30, 2021

Electronic claim response files

Medical Policy & Clinical GuidelinesCommercialJune 30, 2021

Medical policy updates and clinical guideline updates

Reimbursement PoliciesCommercialJune 30, 2021

New reimbursement policy: Non-patient Laboratory Services (Facility)

Reimbursement PoliciesCommercialJune 30, 2021

Reimbursement policy update: Consultations (Professional)

State & FederalMedicaidJune 30, 2021

Let’s Vaccinate

State & FederalMedicaidJune 30, 2021

Medical drug benefit Clinical Criteria updates

State & FederalMedicaidJune 30, 2021

Coding spotlight: mental disorders in childhood

State & FederalMedicaidJune 30, 2021

What Matters Most: Improving the Patient Experience

State & FederalMedicaidJune 30, 2021

Resources to support your diverse patient panel

State & FederalMedicaidJune 30, 2021

Keep up with Medicaid news

State & FederalMedicare AdvantageJune 30, 2021

Let’s Vaccinate

State & FederalMedicare AdvantageJune 30, 2021

Medical drug benefit Clinical Criteria updates

AdministrativeCommercialJune 30, 2021

Surgical Clinical Site of Care review updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Members enrolled in Empire BlueCross BlueShield (“Empire”) commercial plans require a medical necessity review of the site of care for numerous surgical procedures performed in an outpatient hospital setting with dates of service on or after January 1, 2021. Clinical guideline CG-SURG-52, Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services will apply to the review process. AIM Specialty Health® (AIM) will administer the review.

 

Providers are encouraged to obtain privileges at a non-hospital-based facility.   To allow sufficient time for providers to obtain privileges at a non-hospital-based facility, providers may attest to lack of privileges when requesting a prior authorization. Please note that effective September 1, 2021, an outpatient hospital department will only be approved when medical necessity is met to use a hospital site of service. 

 

If you have questions around which participating ASCs are nearest to your location, please email us at ASCPrivilegingSupport@anthem.com

 

For additional information, please refer the October Newsletter.

 

The site of care review only applies to outpatient procedures performed in a hospital-based facility.   The site of care review does not apply to outpatient procedures performed in a non-hospital-based facility or as part of an inpatient stay, nor when Empire is the secondary payer.

 

For a complete list of procedures included in this site of care review, Frequently Asked Question and additional information, visit aimproviders.com/surgicalprocedures/resources

 

Providers should always use the Empire assigned member ID number and continue to verify eligibility and benefits for all members prior to rendering services.

 

The AIM reviews apply to local fully insured Empire members and any member covered under self-insured (ASO) benefit plans with services medically managed by AIM; to include the City of NY.

 

They do not apply to BlueCard®, Medicare Advantage, Medicaid, Medicare Supplement, Federal Employee Program® (FEP®) or ASO benefit plans where services are not medically managed by AIM.  Providers can view specific guidelines and prior authorization requirements for Empire members on the Prior Authorization page of our empireblue.com/provider. 

 

If you have questions, please call the Provider Service phone number on the back of the member’s ID card.

 

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AdministrativeCommercialJune 30, 2021

Proper coding for in-home monitoring can make a measurable difference for INR

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

It wasn’t too long ago when patients taking warfarin (brand name Coumadin) were heading off to the lab or clinic every few weeks for an international normalized ratio (INR) blood test. Thanks to a small, portable device, patients on warfarin can now self-test with a finger prick drop of blood. There is more to self-testing than the ease and convenience, though. Patients are happier! Their quality of life improved because they can keep up with their activities – even travel, without the stress of making and keeping testing appointments.

 

Self-testing: Measurable difference when correct coding is reflected

This type of quality care and improved outcomes are making a measurable difference in the lives of our members. We want this success accounted for in the INR clinical quality measure and with your help, we can do it.  Use these codes to reflect INR In-home monitoring when noting the INR results for your patients.

 

Value set ID and subgroup

Code

Description

INR HOME MONITORING

CPT CODE 93792

Patient/caregiver training for initiation of home INR monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver's ability to perform testing and report results.

INR HOME MONITORING

CPT CODE 93793

Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab INR test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed.

INR HOME MONITORING

HCPCS CODE G0248

Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient's ability to perform testing and report results.

INR HOME MONITORING

HCPCS CODE G0249

Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes: provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a week; testing materials, billing units of service include four tests.

INR HOME MONITORING

HCPCS CODE G0250

Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include four tests.

 

INR clinical quality measure:

The percentage of members 18 years of age and older who had at least one 56-day interval of warfarin therapy and who received at least one international normalized ratio (INR) monitoring test during each 56-day interval with active warfarin therapy.

 

Clinical Quality Measure

Required documentation

CPT, HCPCS, LOINC and                                           CPT Performance Codes

Provider Specialty

INR Monitoring for Individuals on Warfarin*

 

Adults 18 years of age and older who have had at least one 56- day interval of warfarin therapy and received at least one INR monitoring test during each 56-day interval with active warfarin therapy in the measurement year. Excludes patients who are monitoring INR at home during the treatment period

CPT 85610 - Prothrombin time
LOINC 34714-6 INR blood by coagulation assay
6301-6 INR in platelet poor plasma by coagulation assay
38875-1 INR in platelet poor plasma or blood by coagulation assay
46418-0 INR in capillary blood by coagulation assay
52129-4 INR in platelet poor plasma by coagulation - post heparin adsorption

Excludes:
G0248 - demonstrate use home INR monitoring
G0249 - provide test materials and equipment for home INR monitoring
G0250 - physician INR test review interpretation and management

No provider type restrictions

 

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AdministrativeCommercialJune 30, 2021

Another mark of the pandemic: an increase in childhood obesity

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

More potato chips, sugary drinks and less physical activity are key contributors

In a recent study published by Pediatrics1, economic hardship, school closing and shutdowns led to sedentary lifestyles and increases in childhood obesity. The research analyzed doctor visits pre-pandemic then during the pandemic period and the increases were dramatic. Overall obesity increased from 13.7% to 15.4%. Increases observed ranged from 1% in children aged 13 to 17 years to 2.6% for those aged 5 to 9 years.

 

The study recommended new approaches to Weight Assessment and Counseling. These include recommending virtual activities that promote increased physical activity. Focusing on ways to remain safe and active with outside activities, such as park visits, walks and bike riding were also suggested.

 

The Centers for Disease Control and Prevention has a great resource, “Ways to promote health with preschoolers.” This fun flyer shows how we can all work together to support a healthy lifestyle. You can download a copy here.

 

The HEDIS® measure Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) requires a nutritional evaluation and pro-active guidance as part of a routine health visit.

  • When counseling for nutrition, document current nutritional behavior, such as meal patterns, eating and diet habits, and weight counseling.
  • When counseling for physical activity, document current physical activity behavior, such as exercise routine, participation in sports activities, bike riding and play groups.
  • Handouts about nutrition and physical activity also count toward meeting this HEDIS measure when documented in the member’s health record.

 

HEDIS® measure WCC looks at the percentage of members, 3-17 years of age, who had an outpatient visit with a PCP or OB/GYN and have documented evidence for all the following during the measurement year:

  • Body mass index (BMI) percentile (percentage, not value)
  • Counseling for nutrition
  • Counseling for physical activity

 

Telehealth, virtual check-in, and telephone visits all meet the criteria for nutrition and physical activity counseling. Counseling does not need to take place only during a well-visit, WCC can also be completed during sick visits. Documenting guidance in your patient’s records is key.




Code services correctly to measure success
These diagnosis and procedure codes are used to document BMI percentile, weight assessment, and counseling for nutrition and physical activity:

 

Description

CPT®

ICD-10-CM

HCPCS

BMI percentile

 

Z68.51-Z68.54

 

Counseling for nutrition

97802, 97803,

97804

Z71.3

G0270, G0271, G0447, S9449,

S9452, S9470

Counseling for physical activity

 

Z02.5, Z71.82

G0447, S9451

Codes to identify outpatient visits:
CPT
— 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99429, 99455, 99456, 99483
HCPCS — G0402, G0438, G0439, G0463, T1015

 

 

 

 

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

 

American Academy of Pediatrics. American Academy of Pediatrics raises concern about children’s nutrition and physical activity during pandemic. Available at: http://services.aap.org/en/news-room/news-releases/aap/2020/american-academy-of-pediatrics-raises-concern-about-childrens-nutrition-and-physical-activity-during-pandemic/. Accessed December 10, 2020

1 https://pediatrics.aappublications.org/content/147/5/e2021050123?cct=2287#F1

 

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AdministrativeCommercialJune 30, 2021

Timely receipt of primary payer’s EOB can help reduce timely filing denials for secondary claims

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Many members have both primary and secondary insurance policies, and it’s important to know which policy is primary. We want to make it as easy as possible for you to find out so you can avoid claim denials for not filing the secondary claim within the timely filing guidelines.

 

Before the member arrives for their appointment, check the primary insurance carrier using the Eligibility and Benefits app in Availity. Log onto Availity.com, go to payer spaces, select us as the payer and use the Patient Registration tab to run an Eligibility and Benefits Inquiry. If you find that we are the primary payer, confirm that when the member arrives for their appointment. After providing services, submit the member’s claim as usual – you can use Availity for that, too, through the Claims & Payments app.

 

If we are the secondary payer, we will need the explanation of benefits (EOB) from the primary carrier along with the claim submission to determine our payment amount. You can submit the EOB and the claim through Availity using the Claims & Payments app.

 

When a claim is submitted to us as the primary payer, and we are the secondary payer, our claim system will deny the claim because we don’t have the EOB. This can cause a delay in receipt of your payment and can even cause you to miss the timely filing guideline.

 

We want you to have of the information you need to know the very best way to file your claims. For more information about filing claims, visit empireblue.com/provider/claims-submissions. For help using Availity, log onto Availity.com and select the Help & Training tab.

 

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AdministrativeCommercialJune 30, 2021

Register now to learn strategies to help you and your practice improve clinical quality

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.



Overview:

Join us throughout the year in a new Continuing Medical Education (CME) webinar series as we share practices and success stories to overcoming barriers in achieving clinical quality goals, attaining better patient outcomes and improving Star ratings.

 

Program objectives:

  • Learn strategies to help you and your healthcare team improve your performance across a range of clinical areas including telehealth, pharmacy measures, chronic disease monitoring, cancer screenings, documentation and more.
  • Apply the knowledge you gain from the webinars to improve your organization’s quality.

 

Attendees will receive one CME credit upon completion of a program evaluation at the conclusion of each webinar.

 

REGISTER HERE for our upcoming clinical quality webinars!                

 

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AdministrativeCommercialJune 30, 2021

Commercial Repapering: Important update

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Empire has sent out a large volume of contracts in a Commercial repapering effort. The repapering effort does not impact existing rates or networks.

 

Please send back the signed signature page as soon as possible so that we can ensure we have an updated agreement in the system.

 

Send to:

          Empire BlueCross BlueShield

          9 Pine St. 21st Fl.

          New York, NY 10005

 

Please ensure that you review the information in the agreement thoroughly.  Due to the volume of contracts that providers have returned back to Empire, you may not have received an email regarding receipt of the agreement at this point.

 

1244-0721-PN-NY

 

Digital SolutionsCommercialJune 30, 2021

How to enroll in electronic fund transfer (EFT) for faster remittance

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Like the payroll direct deposit service that most businesses offer their employees, electronic funds transfer (EFT) is a digital payment solution that uses the automated clearinghouse (ACH) network to transmit health care payments from a health plan to a health care provider’s bank account. Health plans can use a provider’s banking information only to deposit funds, not to withdraw funds.

 

Empire BlueCross BlueShield (“Empire”) expects providers to accept payment via EFT in lieu of paper checks. Providers can register or manage account changes for EFT via the CAQH enrollment tool called EnrollHub™. This tool will help eliminate the need for paper registration, reduce administrative time and costs and allows physicians and facilities to register with multiple payers at one time. By eliminating paper checks, EFT payments are deposited directly into your account faster.

 

Read more about going digital with Empire in the Provider Digital Engagement Supplement available online.  Go to empireblue.com, select Providers, under the Provider Resources heading select Forms and Guides.  Pick your state if you haven’t done so already.  From the Category drop down, select Digital Tools, then Provider Digital Engagement Supplement.

 

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Digital SolutionsCommercialJune 30, 2021

Electronic claim response files

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Empire BlueCross BlueShield (“Empire”) uses Availity as its exclusive partner for managing all electronic data interchange (EDI) transactions.

 

When your organizations claims are submitted either by your Clearinghouse/Vendor or submitted directly using practice management software, it’s important to review and utilize all responses to understand where your claims are in the adjudication process and if any action is required.

 

Below is a summary of the process for electronic files, and the response reports that are returned by Availity:

 

Electronic file is submitted to Availity

  • Availity Acknowledges receipt of file and validates for X12 format in a series of responses.
  • The series of initial responses indicate whether an electronic file was successfully received in correct format and accepted by Availity.
  • If errors occur, the impacted file will require resubmission to Availity.
  • If your organization uses a Clearinghouse/Vendor, they are responsible for reviewing these response files.

 

HIPAA and Business Validation

  • Electronic Batch Report (EBR) - This response acknowledges accepted claims and identifies claims with a HIPAA and business edits prior to routing for adjudication.
  • Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice. (Edit examples include - Invalid subscriber ID for the date of service and invalid billing and coding per industry standards)
  • Clearinghouse/Vendors may provide their own version of this report to your organization.

 

Availity routes claims to payer Empire

  • Delayed Payer Report (DPR) - This response file contains an additional level of editing by the membership adjudication system.
  • Currently this response only returns for the Medicare/ Medicaid lines of business.
  • The commercial lines will return this response in the future, look for forthcoming communications with the details.
  • Impacted claims require resubmission to view on payer spaces Remittance Inquiry Tool and the (835) Electronic Remittance Advice.
  • Clearinghouses/Vendors may provide their own version of this report to your organization.

 

If you have further questions on the response reports, please contact Availity at 1-800-282-4548.

 

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Digital SolutionsCommercialJune 30, 2021

Interactive Care Reviewer (ICR): New search option for cases submitted through ICR

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Locating a case using Interactive Care Reviewer (ICR), Empire BlueCross BlueShield’s (“Empire”) digital authorization tool just got easier.  We added the ICR Case Search tab within the tool so you can find cases submitted through ICR. Cases submitted through both ICR and other sources can still be located using the other search options: Member, Date Range, Reference/Authorization Request number or Discharge Date.

 

The steps to access ICR through the Availity Portal have not changed. You are required to have the Authorization & Referral Request role or the Authorization & Referral Inquiry role. Your organization’s Availity administrator can assign these roles.

  1. Log onto Availity’s home page with your unique user ID and password
  2. Select Patient Registration
  3. Select Authorizations & Referrals
  4. Select Authorization Inquiry
  5. Choose the Payer and Organization
  6. Accept the ICR Disclaimer


Here is what’s new:

The ICR Inquiry dashboard displays the new ICR Case Search tab. This new option is currently available for users who have the Authorization & Referral Request role. Users with the Authorization & Referral Inquiry role will be able to access the ICR Case Search tab in mid-July. Until then, the additional search options are available.

 

To locate a case submitted through ICR, select the ICR Case Search tab then choose the criteria to complete your search.




Use the additional search options to find cases submitted through both ICR and other sources.

 

Register for our monthly new user ICR webinar to learn about basic navigation and features: ICR Webinar Registration.

 

Or you can visit the Custom Learning Center located on Availity Payer Spaces to access ICR navigation demonstrations and reference guides.

 

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Medical Policy & Clinical GuidelinesCommercialJune 30, 2021

Medical policy updates and clinical guideline updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

These updates list the new and/or revised Empire 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.

 

To view medical policies and utilization management 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

 

Revised Medical Policy Effective 05-20-2021

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

  • TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors


Revised Medical Policies Effective 06-12-2021

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

  • OR-PR.00003 - Microprocessor Controlled Lower Limb Prosthesis
  • SURG.00129 - Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea or Snoring
  • SURG.00143 - Perirectal Spacers for Use During Prostate Radiotherapy


Revised Medical Policy Effective 07-01-2021

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

  • MED.00098 - Hyperoxemic Reperfusion Therapy

 

Revised Medical Policies Effective 07-01-2021

(The following policies were updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)

  • GENE.00052 - Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
  • LAB.00011 - Analysis of Proteomic Patterns
  • SURG.00097 - Vertebral Body Stapling and Tethering for the Treatment of Scoliosis in Children and Adolescents

 

Revised Medical Policy Effective 07-07-2021

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

  • ANC.00009 - Cosmetic and Reconstructive Services of the Trunk and Groin

 

Revised Medical Policies Effective 07-07-2021

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

  • ADMIN.00002 - Preventive Health Guidelines
  • ADMIN.00004 - Medical Necessity Criteria
  • ADMIN.00005 - Investigational Criteria
  • ADMIN.00007 – Immunizations
  • ANC.00006 - Biomagnetic Therapy
  • ANC.00007 - Cosmetic and Reconstructive Services: Skin Related
  • DME.00024 - Transtympanic Micropressure
  • DME.00030 - Altered Auditory Feedback Devices for the Treatment of Stuttering
  • DME.00037 - Cooling Devices and Combined Cooling/Heating Devices
  • DME.00038 - Static Progressive Stretch (SPS) and Patient-Actuated Serial Stretch (PASS) Devices
  • DME.00039 - Prefabricated Oral Appliances for the Treatment of Obstructive Sleep Apnea
  • DME.00042 - Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea
  • GENE.00010 - Panel and other Multi-Gene Testing for Polymorphisms to Determine Drug-Metabolizer Status
  • GENE.00041 - Genetic Testing to Confirm the Identity of Laboratory Specimens
  • GENE.00051 - Bronchial Gene Expression Classification for Diagnostic Evaluation of Lung Cancer
  • GENE.00053 - Metagenomic Sequencing for Infectious Disease in the Outpatient Setting
  • LAB.00016 - Fecal Analysis in the Diagnosis of Intestinal Disorders
  • LAB.00031 - Advanced Lipoprotein Testing
  • LAB.00035 - Multi-biomarker Disease Activity Blood Tests for Rheumatoid Arthritis
  • MED.00013 - Parenteral Antibiotics for the Treatment of Lyme Disease
  • MED.00090 - Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders
  • MED.00110 - Silver-based Products and Autologous Skin-, Blood- or Bone Marrow-derived Products for Wound and Soft Tissue Applications
  • MED.00127 - Chelation Therapy
  • MED.00131 - Electronic Home Visual Field Monitoring
  • MED.00132 - Adipose-derived Regenerative Cell Therapy and Soft Tissue Augmentation Procedures
  • MED.00133 - Ingestion Event Monitors
  • OR-PR.00005 - Upper Extremity Myoelectric Orthoses
  • OR-PR.00006 - Powered Robotic Lower Body Exoskeleton Devices
  • RAD.00034 - Dynamic Spinal Visualization (Including Digital Motion X-ray and Cineradiography/ Videofluoroscopy)
  • RAD.00063 - Magnetization-Prepared Rapid Acquisition Gradient Echo Magnetic Resonance Imaging (MPRAGE MRI)
  • SURG.00005 - Partial Left Ventriculectomy
  • SURG.00007 - Vagus Nerve Stimulation
  • SURG.00010 - Treatments for Urinary Incontinence
  • SURG.00045 - Extracorporeal Shock Wave Therapy
  • SURG.00047 - Transendoscopic Therapy for Gastroesophageal Reflux Disease, Dysphagia and Gastroparesis
  • SURG.00071 - Percutaneous and Endoscopic Spinal Surgery
  • SURG.00076 - Nerve Graft after Prostatectomy
  • SURG.00084 - Implantable Middle Ear Hearing Aids
  • SURG.00105 - Bicompartmental Knee Arthroplasty
  • SURG.00111 - Axial Lumbar Interbody Fusion
  • SURG.00116 - High Resolution Anoscopy Screening for Anal Intraepithelial Neoplasia (AIN) and Squamous Cell Cancer of the Anus
  • SURG.00118 - Bronchial Thermoplasty
  • SURG.00120 - Internal Rib Fixation Systems
  • SURG.00125 - Radiofrequency and Pulsed Radiofrequency Treatment of Trigger Point Pain
  • SURG.00126 - Irreversible Electroporation
  • SURG.00134 - Interspinous Process Fixation Devices
  • SURG.00140 - Peripheral Nerve Blocks for Treatment of Neuropathic Pain
  • SURG.00141 - Doppler-Guided Transanal Hemorrhoidal Dearterialization
  • SURG.00145 - Mechanical Circulatory Assist Devices (Ventricular Assist Devices, Percutaneous Ventricular Assist Devices and Artificial Hearts)
  • SURG.00147 - Synthetic Cartilage Implant for Metatarsophalangeal Joint Disorders
  • THER-RAD.00012 - Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
  • TRANS.00035 - Other Stem Cell Therapy


Archived Medical Policy Effective 07-07-2021

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

  • RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification

 

Archived Medical Policies Effective 07-07-2021

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

  • DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting [Note: Content transferred to CG-DME-48 Vacuum Assisted Wound Therapy in the Outpatient Setting]
  • DME.00034 - Standing Frames [Note: Content transferred to CG-DME-49 Standing Frames]

 

Archived Medical Policies Effective 07-07-2021

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

  • GENE.00042 - Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases]
  • GENE.00046 - Prothrombin (Factor II) Genetic Testing [Note: Content transferred to CG-GENE-13 Genetic Testing for Inherited Diseases]

 

Revised Medical Policy Effective 07-10-2021

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

  • SURG.00095 - Viscocanalostomy and Canaloplasty

 

Archived Medical Policy Effective 09-12-2021

(The following policy has been archived and its content has been transitioned to an AIM guideline and to a new Clinical UM Guideline.)

  • SURG.00127 - Sacroiliac Joint Fusion [Note: Content for minimally invasive sacroiliac joint fusion transitioned to AIM guidelines and content for open sacroiliac joint fusion moved to CG-SURG-111 Open Sacroiliac Joint Fusion]

 

New Medical Policy Effective 10-01-2021

(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.)

  • GENE.00057 - Gene Expression Profiling for Idiopathic Pulmonary Fibrosis

 

Revised Medical Policies Effective 10-01-2021

(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.)

  • DME.00012 - Intrapulmonary Percussive Ventilation Devices
  • LAB.00027 - Selected Blood, Serum and Cellular Allergy and Toxicity Tests
  • SURG.00155 - Cryoneurolysis

 

New Medical Policies Effective 10-02-2021

(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.)

  • LAB.00041 - Machine Learning Derived Probability Score for Rapid Kidney Function Decline
  • MED.00137 - Eye Movement Analysis Using Non-spatial Calibration for the Diagnosis of Concussion

 

Revised Medical Policy Effective 10-02-2021

(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.)

  • MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy and Ultrasonography)

 

Revised Medical Policy Effective 10-16-2021

(The policies 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.)

  • TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection

 

Clinical guideline updates

 

Revised Clinical Guideline Effective 05-20-2021

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

  • CG-SURG-27 - Gender Affirming Surgery

 

Revised Clinical Guideline Effective 07-01-2021

(The following adopted guideline was updated with new CPT/HCPCS/ICD-10-PCS procedure codes and/or ICD-10-CM diagnosis codes.)

  • CG-MED-59 - Upper Gastrointestinal Endoscopy in Adults

 

Archived Clinical Guideline Effective 07-07-2021

(The following guideline has been archived.)

  • CG-MED-75 - Medical and Other Non-Behavioral Health Related Treatments for Autism Spectrum Disorders and Rett Syndrome

 

Revised Clinical Guidelines Effective 07-07-2021

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

  • CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
  • CG-GENE-13 - Genetic Testing for Inherited Diseases [Note: Content moved from GENE.00042 Genetic Testing for Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy Syndrome and GENE.00046 Prothrombin (Factor II) Genetic Testing]
  • CG-SURG-12 - Penile Prosthesis Implantation

 

Revised Clinical Guidelines Effective 07-07-2021

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

  • CG-DME-45 - Ultrasound Bone Growth Stimulation
  • CG-DME-46 - Pneumatic Compression Devices for Prevention of Deep Vein Thrombosis of the Extremities in the Home Setting
  • CG-GENE-10 - Chromosomal Microarray Analysis (CMA) for Developmental Delay, Autism Spectrum Disorder, Intellectual Disability and Congenital Anomalies
  • CG-GENE-11 - Genotype Testing for Individual Genetic Polymorphisms to Determine Drug-Metabolizer Status
  • CG-MED-64 - Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation and Atrial Flutter (Radiofrequency and Cryoablation)
  • CG-MED-76 - Magnetic Source Imaging and Magnetoencephalography
  • CG-MED-77 - SPECT/CT Fusion Imaging
  • CG-MED-87 - Single Photon Emission Computed Tomography Scans for Noncardiovascular Indications
  • CG-SURG-05 - Maze Procedure
  • CG-SURG-08 - Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
  • CG-SURG-34 - Diagnostic Infertility Surgery
  • CG-SURG-35 - Intracytoplasmic Sperm Injection (ICSI)
  • CG-SURG-50 - Assistant Surgeons
  • CG-SURG-71 - Reduction Mammaplasty
  • CG-SURG-81 - Cochlear Implants and Auditory Brainstem Implants
  • CG-SURG-84 - Mandibular/Maxillary (Orthognathic) Surgery
  • CG-SURG-85 - Hip Resurfacing
  • CG-SURG-86 - Endovascular/ Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
  • CG-SURG-87 - Nasal Surgery for the Treatment of Obstructive Sleep Apnea and Snoring
  • CG-SURG-89 - Radiofrequency Neurolysis and Pulsed Radiofrequency Therapy for Trigeminal Neuralgia
  • CG-SURG-101 - Ablative Techniques as a Treatment for Barrett’s Esophagus
  • CG-TRANS-03 - Donor Lymphocyte Infusion for Hematologic Malignancies after Allogeneic Hematopoietic Progenitor Cell Transplantation

 

Revised Clinical Guidelines Effective 07-17-2021

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

  • CG-MED-74 - Implantable Ambulatory Event Monitors and Mobile Cardiac Telemetry

 

Revised Clinical Guideline Effective 10-01-2021

(The following adopted guideline was revised and might result in services that were previously covered but may now be found to be not medically necessary.)

  • CG-SURG-12 - Penile Prosthesis Implantation

 

Revised Clinical Guidelines Effective 10-16-2021

(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-61 - Cryosurgical or Radiofrequency Ablation to Treat Solid Tumors Outside the Liver
  • CG-SURG-71 - Reduction Mammaplasty

 

1225-0721-PN-NY

 

Reimbursement PoliciesCommercialJune 30, 2021

New reimbursement policy: Non-patient Laboratory Services (Facility)

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 October 1, 2021, Empire BlueCross BlueShield (“Empire”) will implement a new reimbursement policy titled Non-Patient Laboratory Services.  Empire does not allow reimbursement for non-patient laboratory services when reported on a UB-04 with bill type 014X unless provider, state, federal or CMS and/or requirements indicate otherwise. 

 

For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.

 

1225-0721-PN-NY

 

Reimbursement PoliciesCommercialJune 30, 2021

Reimbursement policy update: Consultations (Professional)

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 October 1, 2021, Empire BlueCross BlueShield’s (“Empire”) current Documentation and Reporting Guidelines for Consultations policy will be renamed Consultations. This policy aligns with CMS guidance and does not allow reimbursement for inpatient (99251-99255) or outpatient (99241-99245) consultation codes and requires providers to bill the appropriate office visit Evaluation and Management (E&M) code for consultation services.

 

For more information about this policy, visit the Reimbursement Policy page at empireblue.com/provider.

 

1226-0721-PN-NY

Products & ProgramsCommercialJune 30, 2021

Blue Precision program to be retired at the end of the year

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

For more than a decade, Blue Precision – Empire BlueCross BlueShield’s (“Empire”) physician transparency program – has recognized specialists for meeting or exceeding established quality and cost effectiveness measures.  Thank you to all those physicians participating in our networks and for the care you provide to our members.

 

Empire is announcing that we have made the decision to retire our Blue Precision program effective December 31, 2021. Blue Precision recognition icons and other program information will be removed from empireblue.com and our “Find Care” provider tool by January 1, 2022.

 

Going forward, Empire will continue to focus and expand our consumer tools and content to assist members in making more informed and personalized healthcare decisions.  We look forward to working collaboratively with you in other physician programs to provide our members with continued access to affordable and quality healthcare. 

 

1202-0721-PN-NY

Products & ProgramsCommercialJune 30, 2021

Update: Site of Care medical necessity reviews for long-acting colony-stimulating factors will not be implemented on August 1, 2021

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

This is an update to the article published in the April 2021 edition of Provider News regarding Site of Care medical necessity reviews for long-acting colony-stimulating factors.

 

The program will not be implemented on August 1, 2021. Medical necessity review of the site of care for the following long acting colony-stimulating factors for oncology indications will not be required beginning August 1, 2021, as originally communicated.  

  • Neulasta® and Neulasta Onpro® (pegfilgrastim)
  • Fulphila® (pegfilgrastim-jmdb)
  • Udenyca® (pegfilgrastim-cbqv)
  • Ziextenzo® (pegfilgrastim-bmez)
  • Nyvepria™ (pegfilgrastim-apgf)

 

There will be no changes for ordering providers who submit prior authorization requests for the hospital outpatient site of care for these medications for dates of service on or after August 1, 2021.

 

Providers should continue to verify eligibility and benefits for all members prior to rendering services.

 

If you have questions, please call the Provider Service phone number on the member’s ID card.  

 

1210-0721-PN-NY

 

Products & ProgramsCommercialJune 30, 2021

AIM Rehabilitative program - initial evaluations and site of service reviews

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Please be aware that AIM Specialty Health® (AIM), * a separate company, will not expand the

AIM Rehabilitation program to perform medical necessity review for physical, occupational and speech therapy procedures for the requested site of service at this time. 

 

AIM will continue to manage physical therapy (PT), occupational therapy (OT) and speech therapy (ST) medical necessity reviews and will require prior authorization for all outpatient facility and office-based rehabilitative and habilitative services.

 

How to place a review request

Providers may submit prior authorization requests to AIM in one of several ways: 

  • Access AIM’s ProviderPortallSM directly at http://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.
  • Access AIM via the Availity Portal* at https://www.availity.com.
  • Call the AIM Contact Center toll-free number at 1-800-714-0040 from 7 a.m. to 7 p.m. ET.

 

1235-0721-PN-NY

Federal Employee Program (FEP)CommercialJune 30, 2021

Federal Employee Program® AIM Radiology prior authorization review

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Effective with dates of service on or after October 1, 2021, Empire Federal Employee Program (FEP) will transition all review of diagnostic imaging services to AIM Specialty Health® (AIM). These services will require Prior Authorization to determine medical necessity prior to rendering the service for Empire BlueCross BlueShield (“Empire”) Federal Employee members.

 

Your practice can benefit from participation in several ways, including:

  • Improving the clinical appropriateness of imaging services through the application of evidence-based guidelines in an efficient and effective review process. Empire Federal Employee Program (FEP) will be utilizing the FEP Medical Policy to review for medical necessity. In the absence of a controlling FEP Medical Policy, medical necessity determinations will be made using Empire Medical Policy and/or AIM Clinical Guidelines.
  • Maximizing a health plan’s network value through a wide range of solutions including provider assessment tools, cost and quality transparency and reporting.
  • Engaging consumers in understanding the range of choices they have in selecting imaging providers and increasing their ability to make informed decisions.

 

For services that are scheduled to begin on or after October 1, 2021, all providers must contact AIM to obtain pre-service review for the following non-emergency modalities:

  • Nuclear imaging, including myocardial perfusion imaging, cardiac blood pool imaging, infarct imaging and Positron Emission Tomography (PET) myocardial imaging
  • Computed Tomography (CT), including CT angiography, derived fractional flow reserve, structural CT and quantitative evaluation of coronary calcification
  • Magnetic Resonance Imaging (MRI)
  • Magnetic Resonance Angiography (MRA)
  • Magnetic Resonance Spectroscopy (MRS)
  • Functional MRI (fMRI)
  • Stress Echocardiography (SE)*
  • Resting Echocardiography (TTE)*
  • Transesophageal Echocardiography (TEE)*

 

How to Submit a Request for Review:

Starting September 20, 2021, providers can begin submitting requests for review with dates of service on or after October 1, 2021, or can verify order numbers using one of the following methods as a registered AIM portal provider:

How to register online:


How to register by phone:
  • Call AIM Specialty Health toll-free at 866-789-0397, Monday through Friday between 7:00 a.m. to 7:00 p.m. CT


For more information about the Radiology Program and to help your practice get started
go to: http://www.aimprovider.com/radiology.This website can also help you learn more about provider access to useful information and tools such as order entry checklists and clinical guidelines.

 

Empire Federal Employee Program values 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.

 

1207-0721-PN-NY

 

PharmacyCommercialJune 30, 2021

Certain specialty medication precertification requests may require additional documentation

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

As part of our ongoing quality improvement efforts, Empire BlueCross BlueShield (“Empire”) is updating our precertification processes for certain specialty medications. Effective August 2021, we may request additional documentation for impacted medications to determine medical necessity.

 

Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.

 

Should you have any questions, please refer to the Clinical Criteria policy website at https://www.anthem.com/ms/pharmacyinformation/clinicalcriteria.html for specific medication criteria details, including documentation requirements.

 

Impacted Policy

Impacted Medication(s)

ING-CC-0153: Adakveo (crizanlizumab)

Adakveo

ING-CC-0065: Agents for Hemophiilia A and von Willebrand Disease

Advate, Adynovate, Afstyla, Alphanate, Eloctate, Esperoct, Helixate FS, Hemlibra, Hemofil-M, Humate-P, Jivi, Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha

ING-CC-0148: Agents for Hemophilia B

Alphanine SD, Alprolix, Bebulin, Benefix, Idelvion, Ixinity, Mononine, Profilnine SD, Rebinyn, Rixubis

ING-CC-0025: Aldurazyme (laronidase)

Aldurazyme

ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

ING-CC-0028: Benlysta (belimumab)

Benlysta

ING-CC-0012: Brineura (cerliponase alfa)

Brineura

ING-CC-0137: Cablivi (caplacizumab-yhdp)

Cablivi

ING-CC-0041: Complement Inhibitors

Soliris, Ultomiris

ING-CC-0081: Crysvita (burosumab-twza)

Crysvita

ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)

Duopa

ING-CC-0029: Dupixent (dupilumab)

Dupixent

ING-CC-0069: Egrifta (tesamorelin)

Egrifta

ING-CC-0024: Elaprase (idursufase)

Elaprase

ING-CC-0173: Enspryng (satralizumab-mwge)

Enspryng

ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

ING-CC-0044: Exondys 51 (eteplirsen)

Exondys 51

ING-CC-0021: Fabrazyme (agalsidase beta)

Fabrazyme

ING-CC-0068: Growth hormone

Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive

ING-CC-0034: Hereditary Angioedema Agents

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

ING-CC-0188: Imcivree (setmelanotide)

Imcivree

ING-CC-0070: Jetrea (ocriplasmin)

Jetrea

ING-CC-0037: Kanuma (sebelipase alfa)

Kanuma

ING-CC-0057: Krystexxa (pegloticase)

Krystexxa

ING-CC-0018: Lumizyme (alglucosidase alfa)

Lumizyme

ING-CC-0013: Mepsevii (vestronidase alfa)

Mepsevii

ING-CC-0043: Monoclonal Antibodies to Interleukin-5

Cinqair, Fasenra, Nucala

ING-CC-0023: Naglazyme (galsulfase)

Naglazyme

ING-CC-0111: Nplate (romiplostim)

Nplate

ING-CC-0082: Onpattro (patisiran)

Onpattro

ING-CC-0077: Palynziq (pegvaliase-pqpz)

Palynziq

ING-CC-0049: Radicava (edaravone)

Radicava

ING-CC-0156: Reblozyl (luspatercept)

Reblozyl

ING-CC-0159: Scenesse (afamelanotide)

Scenesse

ING-CC-0149: Select Clotting Agents for Bleeding Disorders

Feiba, Novoseven

ING-CC-0079: Strensiq (asfotase alfa)

Strensiq

ING-CC-0008: Subcutaneous Hormonal Implants

Testopel

ING-CC-0084: Tegsedi (inotersen)

Tegsedi

ING-CC-0162: Tepezza (teprotumumab-trbw)

Tepezza

ING-CC-0170: Uplizna (inebilizumab)

Uplizna

ING-CC-0172: Viltepso (viltolarsen)

Viltepso

ING-CC-0022: Vimizim (elosulfase alfa)

Vimizim

ING-CC-0152: Vyondys 53 (golodirsen)

Vyondys 53

ING-CC-0017: Xiaflex (clostridial collagenase histolyticum) injection

Xiaflex

ING-CC-0033: Xolair (omalizumab)

Xolair

 

1204-0721-PN-NY

 

PharmacyCommercialJune 30, 2021

Clinical Criteria updates for specialty pharmacy

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 May 21, 2021 Clinical Criteria meeting. To access the clinical criteria information please click here.

 

New Clinical Criteria effective June 5, 2021

The following clinical criteria is new.

  • ING-CC-0199 - Empaveli (pegcetacoplan)

 

Revised Clinical Criteria effective June 21, 2021

The following current clinical criteria were revised to expand medical necessity indications or criteria.

  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0062 Tumor Necrosis Factor Antagonists
  • ING-CC-0064 Interleukin-1 inhibitors
  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6
  • ING-CC-0098 Doxorubicin Liposome (Doxil, Lipodox)
  • ING-CC-0099 Abraxane (paclitaxel, protein bound)
  • ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
  • ING-CC-0111 Nplate (romiplostim)
  • ING-CC-0120 Kyprolis (carfilzomib)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0127 Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0142 Somatuline Depot (lanreotide)
  • ING-CC-0150 Kymriah (tisagenlecleucel)
  • ING-CC-0151 Yescarta (axicabtagene ciloleucel)
  • ING-CC-0160 Vyepti (eptinezumab)
  • ING-CC-0161 Sarclisa (isatuximab-irfc)
  • ING-CC-0163 Durysta (bimatoprost implant)
  • ING-CC-0165 Trodelvy (sacituzumab govitecan)

 

Revised Clinical Criteria effective June 21, 2021

The following clinical criteria were reviewed with no significant change to the medical necessity indications or criteria.

  • ING-CC-0002 Colony Stimulating Factor Agents
  • ING-CC-0045 Increlex (mecasermin)
  • ING-CC-0057 Krystexxa (pegloticase)
  • ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • ING-CC-0068 Growth Hormone
  • ING-CC-0069 Egrifta (tesamorelin)
  • ING-CC-0087 Gamifant (emapalumab-lzsg)
  • ING-CC-0092 Adcetris (brentuximab vedotin)
  • ING-CC-0105 Vectibix (panitumumab)
  • ING-CC-0106 Erbitux (cetuximab)
  • ING-CC-0116 Bendamustine agents
  • ING-CC-0134 Provenge (sipuleucel-T)
  • ING-CC-0143 Polivy (polatuzumab vedotin-piiq)
  • ING-CC-0153 Adakveo (crizanlizumab)
  • ING-CC-0162 Tepezza (teprotumumab-trbw)
  • ING-CC-0166 Trastuzumab Agents
  • ING-CC-0171 Zepzelca (lurbinectedin)
  • ING-CC-0175 Proleukin (aldesleukin)
  • ING-CC-0178 Synribo (omacetaxine mepesuccinate)
  • ING-CC-0183 Sogroya (somapacitan-beco)
  • ING-CC-0192 Cosela (trilaciclib)
  • ING-CC-0195 Abecma (idecabtagene vicleucel)

 

Revised Clinical Criteria effective July 1, 2021

The following current clinical criteria was revised to expand medical necessity indications or criteria.

  • ING-CC-0125 Opdivo (nivolumab)

 

Revised Clinical Criteria effective July 1, 2021

The following clinical criteria were updated with new procedure and/or diagnosis codes)

  • ING-CC-0061 Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications
  • ING-CC-0075 Rituximab agents for Non-Oncologic Indications
  • ING-CC-0167 Rituximab Agents for Oncologic Indications Step Therapy
  • ING-CC-0184 Danyelza (naxitamab-gqgk)
  • ING-CC-0185 Oxlumo (lumasiran)
  • ING-CC-0186 Margenza (margetuximab-cmkb)
  • ING-CC-0187 Breyanzi (lisocabtagene maraleucel)
  • ING-CC-0189 Amondys 45 (casimersen)
  • ING-CC-0191 Pepaxto (melphalan flufenamide; melflufen)
  • ING-CC-0192 Cosela (trilaciclib)

 

New Clinical Criteria effective October 1, 2021

The following clinical criteria are new.

  • ING-CC-0196 - Zynlonta (loncastuximab tesirine-lpyl)
  • ING-CC-0197 - Jemperli (dostarlimab)
  • ING-CC-0198 - Relizorb (immobilized lipase) cartridge

 

Revised Clinical Criteria effective October 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-0020 Tysabri (natalizumab)
  • ING-CC-0032 Botulinum Toxin
  • ING-CC-0062 Tumor Necrosis Factor Antagonists
  • ING-CC-0066 Monoclonal Antibodies to Interleukin-6
  • ING-CC-0107 Bevacizumab for Non-ophthalmologic Indications
  • ING-CC-0111 Nplate (romiplostim)
  • ING-CC-0114 Jevtana (cabazitaxel)
  • ING-CC-0124 Keytruda (pembrolizumab)
  • ING-CC-0128 Tecentriq (atezolizumab)
  • ING-CC-0137 Cablivi (caplacizumab-yhdp)
  • ING-CC-0145 Libtayo (cemiplimab-rwlc)
  • ING-CC-0160 Vyepti (eptinezumab)

 

1217-0721-PN-NY

 

PharmacyCommercialJune 30, 2021

Updates for specialty pharmacy are effective October 1, 2021

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 October 1, 2021, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.

 

Please note, inclusion of National Drug Code (NDC) code on your claim will help expedite claim processing of drugs billed with a Not Otherwise Classified (NOC) code.

 

To access the Clinical Criteria information, click here.

 

Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by the medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

HCPCS or CPT Code(s)

Drug

*ING-CC-0195

J3490, J9999, C9399, J3590

Abecma


*
Non-oncology use is managed by the medical specialty drug review team.

** Oncology use is managed by AIM.

 

Step therapy updates

Effective for dates of service on and after October 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 Clinical Criteria information, please click here.

 

Prior authorization clinical review of non-oncology specialty pharmacy drugs will be managed by medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM).

 

Clinical Criteria

Status

Drug(s)

HCPCS Codes

ING-CC-0020

Non-preferred

Tysabri

J2323

 

1221-0721-PN-NY

 

PharmacyCommercialJune 30, 2021

Designated specialty pharmacy network updates effective October 1, 2021

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

As we previously communicated, Empire BlueCross BlueShield’s (“Empire”) Designated Specialty Pharmacy Network requires providers who are not part of the Designated Specialty Pharmacy Network to acquire certain select specialty pharmacy medications administered in the hospital outpatient setting through CVS Specialty Pharmacy.    

 

This update is to advise of the following changes:

 

Effective for dates of service on and after October 1, 2021, the following specialty pharmacy medications will be added to the Designated Medical Specialty Pharmacy drug list. Accordingly, hospitals that are not in the Designated Specialty Pharmacy Network will be required to acquire these specialty medications administered in the hospital outpatient setting from CVS Specialty Pharmacy.

 

HCPCS

Description

Brand Name

Q5117

INJECTION, TRASTUZUMAB-ANNS, BIOSIMILAR 10MG

Kanjinti

J1558

INJECTION, IMMUNE GLOBULIN 100MG

Xembify

Q5123

INJECTION, RITUXIMAB-ARRX, BIOSIMILAR

Riabni

 

To access the current Designated Medical Specialty Pharmacy drug list, please visit empireblue.com, select Providers, select Forms and Guides (under the Provider Resources column), scroll down and select Pharmacy in the Category drop down.  The Designated Medical Specialty Pharmacy drug list may be updated periodically by Empire.

 

If you have questions or would like to discuss the terms and conditions to be included as a Designated Specialty Pharmacy Network provider, please contact your Empire Contract Manager.  Thank you for your continued participation in the Empire networks and the services you provide to our members.

 

1227-0721-PN-NY

 

State & FederalMedicaidJune 30, 2021

Attention facilities: Sending admission, discharge and transfer data to Empire results in improved care management for patients

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.

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for Empire integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Empire:

  • Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
  • Proactively manage care transitions to avoid waste.
  • Close care gaps and educate members about appropriate care settings.

 

Empire would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Empire through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Empire to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

 

NYE-NU-0308-21 May 2021

518933MUPENMUB

 

State & FederalMedicaidJune 30, 2021

Let’s Vaccinate

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Help increase your vaccination rates and close gaps-in-care with these tools and strategies

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

 

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

  • Address disparities for vaccine-preventable diseases.
  • Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
  • Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
  • Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

 

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

 

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.
 

NYE-NU-0331-21 May 2021

 

State & FederalMedicaidJune 30, 2021

New reimbursement policy: Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing (Effective 10/01/21)

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Empire BlueCross BlueShield HealthPlus does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at www.empireblue.com/nymedicaiddoc.

 

NYE-NU-0303-21 May 2021

 

State & FederalMedicaidJune 30, 2021

Prior authorization requirement changes effective September 1, 2021

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Summary of change:

Effective September 1, 2021, prior authorization (PA) requirements will change for the following codes. The medical codes listed below will require PA by Empire BlueCross BlueShield HealthPlus for Medicaid Managed Care members. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added to the following:

  • 0203U — Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness
  • 0208U — Oncology (medullary thyroid carcinoma), mRNA, gene expression analysis of 108 genes, utilizing fine needle aspirate, algorithm reported as positive or negative for medullary thyroid carcinoma
  • 0230U — Androgen receptor (AR) (for example, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions
  • 0231U — Calcium voltage-gated channel subunit alpha 1A (CACNA1A) (for example, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR gene expansions, mobile element insertions, and variants in non-uniquely mappable regions
  • 0232U — Cystatin B (CSTB) (for example, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR expansions, mobile element insertions, and variants in non-uniquely mappable regions
  • 0233U — Frataxin (FXN) (for example, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, STR expansions, mobile element insertions, and variants in non-uniquely mappable regions
  • 0234U — Methyl CpG binding protein 2 (MECP2) (for example, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
  • 0235U — Phosphatase and tensin homolog (PTEN) (for example, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
  • 0236U — Survival of motor neuron 1, telomeric (SMN1) and survival of motor neuron 2, centromeric (SMN2) (for example, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications and deletions, and mobile element insertions
  • 0238U — Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions
  • 0620T — Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed
  • 33995 — Insertion of ventricular assist device, percutaneous, including radiological supervision and interpretation; right heart, venous access only
  • 58999 — Unlisted Proc, Female Genital System (Nonobstetrical)
  • 81191 — Neurotrophic receptor tyrosine kinase 1 (NTRK1) (for example, solid tumors) translocation analysis
  • 81192 — Neurotrophic receptor tyrosine kinase 2 (NTRK2) (for example, solid tumors) translocation analysis
  • 81193 — Neurotrophic receptor tyrosine kinase 3 (NTRK3) (for example, solid tumors) translocation analysis
  • 81194 — Neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3 (NTRK) (for example, solid tumors) translocation analysis
  • 81279 — Janus kinase 2 (JAK2) (for example, myeloproliferative disorder) targeted sequence analysis (for example, exons 12 and 13)
  • 81338 — MPL proto-oncogene, thrombopoietin receptor (MPL) (for example, myeloproliferative disorder) gene analysis; common variants (for example, W515A, W515K, W515L, W515R)
  • 81339 — MPL proto-oncogene, thrombopoietin receptor (MPL) (for example, myeloproliferative disorder) gene analysis; sequence analysis, exon 10
  • 81351 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; full gene sequence
  • 81352 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (for example, 4 oncology)
  • 81353 — Tumor protein 53 (TP53) (for example, Li-Fraumeni syndrome) gene analysis; known familial variant
  • 81546 — Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (for example, benign or suspicious)
  • C1778 — Lead, neurostimulator (implantable)
  • C1787 — Patient programmer, neurostimulator
  • G0068 — Professional services for the administration of antiinfective, pain management, chelation, pulmonary hypertension, and/or inotropic infusion drug(s) for each infusion drug administration calendar day in the individual's home, each 15 minutes
  • G0069 — Professional services for the administration of subcutaneous immunotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes
  • G0070 — Professional services for the administration of chemotherapy for each infusion drug administration calendar day in the individual's home, each 15 minutes
  • G0088 — Professional services, initial visit, for the administration of anti-infective, pain management, chelation, pulmonary hypertension, inotropic, or other intravenous infusion drug or biological (excluding chemotherapy or other highly complex drug or biological) for each infusion drug administration calendar day in the individual's home, each 15 minutes
  • G0089 — Professional services, initial visit, for the administration of subcutaneous immunotherapy or other subcutaneous infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes
  • G0090 — Professional services, initial visit, for the administration of intravenous chemotherapy or other highly complex infusion drug or biological for each infusion drug administration calendar day in the individual's home, each 15 minutes


To request PA, you may use one of the following methods:

  • Web: Once logged in to Availity* at http://availity.com, select Patient Registration > Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry, as appropriate.
  • Fax: 800-964-3627
  • Phone: 800-450-8753

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers the provider website at https://providerpublic.empireblue.com > Login. Contracted and noncontracted providers who are unable to access the provider website may call our Provider Services at 800-450-8753 for assistance with PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0329-21 May 2021

 

State & FederalMedicaidJune 30, 2021

Certain specialty medication precertification requests may require additional documentation

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

As part of our ongoing quality improvement efforts, Empire BlueCross BlueShield HealthPlus is updating our precertification processes for certain specialty medications. Effective August 1, 2021, we may request additional documentation for impacted medications to determine medical necessity.

 

Upon request, providers shall submit documentation from the member’s medical record for each policy question flagged for documentation. A denial may result if documentation does not support medical necessity.

 

Should you have any questions, please refer to the Clinical Criteria policy website for specific medication criteria details.

 

Impacted policy

Impacted medication(s)

ING-CC-0153: Adakveo (crizanlizumab)

Adakveo

ING-CC-0065: Agents for Hemophiilia A and von Willebrand Disease

Advate, Adynovate, Afstyla, Alphanate, Eloctate, Esperoct, Helixate FS, Hemlibra, Hemofil-M, Humate-P, Jivi, Koate-DVI, Kogenate FS, Kovaltry, Monoclate-P, Novoeight, Nuwiq, Obizur, Recombinate, Wilate, Xyntha

ING-CC-0148: Agents for Hemophilia B

Alphanine SD, Alprolix, Bebulin, Benefix, Idelvion, Ixinity, Mononine, Profilnine SD, Rebinyn, Rixubis

ING-CC-0025: Aldurazyme (laronidase)

Aldurazyme

ING-CC-0073: Alpha-1 Proteinase Inhibitor Therapy

Aralast, Glassia, Prolastin-C, Zemaira

ING-CC-0028: Benlysta (belimumab)

Benlysta

ING-CC-0012: Brineura (cerliponase alfa)

Brineura

ING-CC-0137: Cablivi (caplacizumab-yhdp)

Cablivi

ING-CC-0041: Complement Inhibitors

Soliris, Ultomiris

ING-CC-0081: Crysvita (burosumab-twza)

Crysvita

ING-CC-0035: Duopa (carbidopa and levodopa enteral suspension)

Duopa

ING-CC-0029: Dupixent (dupilumab)

Dupixent

ING-CC-0069: Egrifta (tesamorelin)

Egrifta

ING-CC-0024: Elaprase (idursufase)

Elaprase

ING-CC-0173: Enspryng (satralizumab-mwge)

Enspryng

ING-CC-0051: Enzyme Replacement Therapy for Gaucher Disease

Cerezyme, Elelyso, Vpriv

ING-CC-0044: Exondys 51 (eteplirsen)

Exondys 51

ING-CC-0021: Fabrazyme (agalsidase beta)

Fabrazyme

ING-CC-0068: Growth hormone

Genotropin, Humatrope, Norditropin, Nutropin AQ, Omnitrope, Saizen, Serostim, Zomacton, Zorbtive

ING-CC-0034: Hereditary Angioedema Agents

Berinert, Cinryze, Firazyr, Haegarda, Kalbitor, Ruconest, Takhzyro

ING-CC-0188: Imcivree (setmelanotide)

Imcivree

ING-CC-0070: Jetrea (ocriplasmin)

Jetrea

ING-CC-0037: Kanuma (sebelipase alfa)

Kanuma

ING-CC-0057: Krystexxa (pegloticase)

Krystexxa

ING-CC-0018: Lumizyme (alglucosidase alfa)

Lumizyme

ING-CC-0013: Mepsevii (vestronidase alfa)

Mepsevii

ING-CC-0043: Monoclonal Antibodies to Interleukin-5

Cinqair, Fasenra, Nucala

ING-CC-0023: Naglazyme (galsulfase)

Naglazyme

ING-CC-0111: Nplate (romiplostim)

Nplate

ING-CC-0082: Onpattro (patisiran)

Onpattro

ING-CC-0077: Palynziq (pegvaliase-pqpz)

Palynziq

ING-CC-0049: Radicava (edaravone)

Radicava

ING-CC-0156: Reblozyl (luspatercept)

Reblozyl

ING-CC-0159: Scenesse (afamelanotide)

Scenesse

ING-CC-0149: Select Clotting Agents for Bleeding Disorders

Feiba, Novoseven

ING-CC-0079: Strensiq (asfotase alfa)

Strensiq

ING-CC-0008: Subcutaneous Hormonal Implants

Testopel

ING-CC-0084: Tegsedi (inotersen)

Tegsedi

ING-CC-0162: Tepezza (teprotumumab-trbw)

Tepezza

ING-CC-0170: Uplizna (inebilizumab)

Uplizna

ING-CC-0022: Vimizim (elosulfase alfa)

Vimizim

ING-CC-0152: Vyondys 53 (golodirsen)

Vyondys 53

ING-CC-0017: Xiaflex (clostridial collagenase histolyticum) injection

Xiaflex

ING-CC-0033: Xolair (omalizumab)

Xolair

 

NYE-NU-0330-21 May 2021

 

State & FederalMedicaidJune 30, 2021

Medical drug benefit Clinical Criteria updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following 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.

 

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

 

Effective date

Document number

Clinical Criteria title

New or revised

July 16, 2021

ING-CC-0195*

Abecma (idecabtagene vicleucel)

New

July 16, 2021

ING-CC-0191*

Pepaxto (melphalan flufenamide; melflufen)

New

July 16, 2021

ING-CC-0192*

Cosela (trilaciclib)

New

July 16, 2021

ING-CC-0193*

Evkeeza (evinacumab)

New

July 16, 2021

ING-CC-0194*

Cabenuva (cabotegravir extended‑release; rilpivirine extended-release) Injection

New

July 16, 2021

ING-CC-0125

Opdivo (nivolumab)

Revised

July 16, 2021

ING-CC-0064

Interleukin-1 Inhibitors

Revised

July 16, 2021

ING-CC-0159*

Scenesse (afamelanotide)

Revised

July 16, 2021

ING-CC-0151

Yescarta (axicabtagene ciloleucel)

Revised

July 16, 2021

ING-CC-0145*

Libtayo (cemiplimab-rwlc)

Revised

July 16, 2021

ING-CC-0130*

Imfinzi (durvalumab)

Revised

July 16, 2021

ING-CC-0127

Darzalex (daratumumab) and Darzalex Faspro (daratumumab and hyaluronidase-fihj)

Revised

July 16, 2021

ING-CC-0075*

Rituximab Agents for Non-Oncologic Indications

Revised


NYE-NU-0335-21 May 2021

 

State & FederalMedicaidJune 30, 2021

Retraction: AIM Rehabilitative program — initial evaluations and site of service reviews

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

AIM Specialty Health® (AIM)* previously announced in an earlier notice that they were scheduled to expand the AIM Rehabilitation program to perform medical necessity review evaluations for physical, occupational, and speech therapy procedures for the requested site of service. The schedule has been delayed until further notice. The program effective date of August 1, 2021, is no longer valid.

 

AIM will continue to manage physical, occupational, and speech therapy medical necessity reviews and will require prior authorization for all outpatient facility and office-based rehabilitative and habilitative services.

 

How to place a review request

Providers may submit prior authorization requests to AIM in one of several ways:

  • Access AIM’s ProviderPortalSM directly at http://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.
  • Access AIM via the Availity Portal* at https://www.availity.com.
  • Call the AIM Contact Center toll-free number at 800-714-0040 from 7 a.m. to 7 p.m. ET.

 

*AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield HealthPlus. Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus.

 

NYE-NU-0332-21 May 2021

State & FederalMedicaidJune 30, 2021

Updates to AIM Specialty Health Musculoskeletal program clinical appropriateness guidelines

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Summary of update:

The following updates will be effective for dates of service on and after
September 12, 2021. The following updates will apply to the AIM Musculoskeletal Program: Joint Surgery, Spine Surgery, and Interventional Pain Clinical Appropriateness Guidelines. These AIM Specialty Health®* guideline updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

 

Joint surgery updates by section

Shoulder arthroplasty:

  • Added steroid injection for all joints; exclusion based on panel recommendation.
  • 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.
  • Removed indication for subacromial impingement with rotator cuff tear.  

Hip arthroplasty:

  • Added exclusion for steroid injection for joint being replaced within the past six weeks.
  • Added labral tear indication.

Knee arthroscopy and open procedures:

  • Added chondroplasty indication.
  • Narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella.
  • Added a conservative management and advanced osteoarthritis exclusion to patellar compression syndrome section.

 

Musculoskeletal program: Interventional pain management guideline updates by section

General requirements — conservative management:

  • Addition of physical therapy or home therapy requirement and one complementary modality based on preponderance of benefit over harm to conservative care.
  • Aligned with approach to conservative management defined in spine and joint surgery guidelines.

Epidural injection procedures and diagnostic selective nerve root blocks:

  • Addition of statement about adherence to the emergency severity index (ESI) procedural best practices established by FDA Safe Use Initiative. Recommendations are intended for provider education and will not be used for adjudication.
  • Clarification of intent around requirement for advanced imaging for repeat injections.

Paravertebral facet injection/nerve block/neurolysis:

  • Removed indication for four unilateral medial branch blocks per session based on panel consensus
  • Procedural clarification restricting use of corticosteroids for diagnostic medial branch block (MBB) based on panel consensus.
  • Limited use of intra-articular steroid injection to mechanical disruption of a facet synovial cyst.
  • Removed indication for intra-articular steroid injections based on new evidence for lack of efficacy.
  • Increased duration of initial radiofrequency neurotomy (RFN) efficacy needed to avoid a MBB to six months based on panel consensus.
  • Clarification that MBB or RFN is not medically necessary after spinal fusion.

Spinal cord and nerve root stimulators:

  • Clarified inclusion of different stimulation methods for spinal cord stimulation.
  • Added new indication for dorsal root ganglion stimulation.
  • Clarified exclusions for spinal cord and dorsal root ganglion stimulation.

 
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 Portal* at availity.com
  • . Call the AIM Contact Center toll-free number at 800-714-0040, Monday through Friday, from 7 a.m. to 7 p.m. Eastern time.

 

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.

 

If you have any questions regarding this communication or any other items, you can call Provider Services at 800-450-8753.

 

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Empire BlueCross BlueShield HealthPlus. Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield HealthPlus.

NYE-NU-0333-21 May 2021

State & FederalMedicaidJune 30, 2021

Coding spotlight: mental disorders in childhood

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Mental disorders among children may cause serious changes in the way children typically learn, behave or handle their emotions, which cause distress and problems getting through the day. Healthcare professionals use the guidelines in the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5),1 to help diagnose mental health disorders in children.

 

The most common mental disorders of childhood and adolescence fall into the following categories:

  • Anxiety disorders (generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobic disorder)
  • Depression
  • Posttraumatic stress disorder (PTSD)
  • Separation anxiety disorder
  • Social anxiety disorder
  • Obsessive-compulsive disorder
  • Bipolar disorder
  • Disruptive behavioral disorders (attention-deficit/hyperactivity disorder ADHD, conduct disorder, and oppositional defiant disorder)
  • Eating disorders
  • Schizophrenia (less common).

 

Other conditions and concerns that affect children’s learning, behavior and emotions include learning and developmental disabilities, autism, and risk factors like substance use and self-harm.

 

ICD-10-CM coding:

  • Chapter 5 of the ICD-10-CM code set categorizes mental disorders.
  • Codes from chapter 5 are assigned based on the express documentation of the provider’s clinical judgment regarding the patient’s mental or behavioral disorder(s). The codes are not assigned based on symptoms, signs, or abnormal clinical laboratory findings.

 

Affective disorders

 

Major depressive disorder (MDD) is classified in ICD-10-CM as:

  • F32: Major depressive disorder, single episode
  • F33: Major depressive disorder, recurrent

 

When documenting major depressive disorder, keep in mind that proper and specific coding requires clear documentation of the:

  • Episode: single versus recurrent.
  • Severity: mild, moderate, or severe.
  • Psychotic features, when present.
  • Status of remission as either partial or full.

 

Remember to document any established causality between multiple mental health conditions. For example:

  • Suppose the patient has a diagnosis of depression and a diagnosis of anxiety with a causal relationship between the two conditions. In such cases, documentation must establish the relationship by stating depression with, due to, or related to anxiety

 

ICD-10-CM classifies bipolar disorders under the following categories:

  • F30: Manic episode (bipolar disorder, single manic episode, and mixed affective episode)
  • F31: Bipolar disorder (manic-depressive illness, manic-depressive psychosis, and manic-depressive reaction)
  • F34: Persistent mood affective disorders (cyclothymic disorder and dysthymic disorder)
  • F39: Unspecified mood affective disorder (affective psychosis not otherwise specified).

 

Nonpsychotic mental disorders

Anxiety, dissociative, stress-related, somatoform and other nonpsychotic mental disorders are classified in categories F40 to F48.

 

Anxiety disorders are classified in ICD-10-CM under the following categories:

  • F40: Phobic anxiety disorders
  • F41: Other anxiety disorders
  • F42: Obsessive-compulsive disorder.

 

Reactions to stress

ICD-10-CM provides category F43 for coding reactions to severe stress and adjustment disorders. Code F43.0, Acute stress reaction, classifies acute reaction to stress, including acute crisis reaction, crisis state, and psychic shock.

 

Posttraumatic stress disorder (PTSD) is classified in ICD-10-CM to subcategory F43.1, with fifth-characters for unspecified, acute, or chronic.

 

Adjustment disorders are classified to subcategory F43.2, with the fifth-character axis being the nature of the reaction, such as anxiety, depression, or other symptoms. For example:

  • 24: Child adopted from a foreign country, suffering from culture shock with conduct disturbance.

 

Behavioral syndromes associated with physiological disturbances and physical factors

Categories F50 to F59 are devoted to behavioral syndromes associated with physiological disturbances and physical factors. These codes are not assigned when the conditions are present due to mental disorders classified elsewhere or organic in origin. This grouping includes, for example:

  • Eating disorders (such as anorexia nervosa and bulimia nervosa)
  • Sleep disorders, not due to a substance or known physiological condition
  • F54*: Psychological and behavioral factors associated with disorders or diseases classified elsewhere

F59: Unspecified behavioral syndromes associated with physiological disturbances and physical factors

* Code F54 classifies psychological and behavioral factors associated with diseases classified elsewhere. Typical conditions that are often associated with code F54 include asthma and dermatitis.

 

Schizophrenic disorders:

  • Those types of disorders are classified in category F20, with a fourth character indicating the type of schizophrenia.
  • The codes from category F20 are followed by an excludes one note indicating they should not be reported with codes classifying a brief psychotic disorder (F23) , cyclic schizophrenia (F25.0), schizoaffective disorder (F25-F25.9) and schizophrenic reaction not otherwise specified (NOS) (F23).
  • Assign code F20.9, Schizophrenia, unspecified, for chronic schizophrenia with acute exacerbation. The existing ICD-10-CM codes for schizophrenia do not differentiate severity or an acute exacerbation (AHA Coding Clinic, Second Quarter 2019, p.32).

 

Attention deficit hyperactivity disorder (ADHD)

 

ICD-10-CM codes for ADHD include:

  • 0: Attention-deficit hyperactivity disorder, predominantly inattentive type.
  • 1: Attention-deficit hyperactivity disorder, predominantly hyperactive type.
  • 2: Attention-deficit hyperactivity disorder, combined type.
  • 8: Attention-deficit hyperactivity disorder, other types.
  • 9: Attention-deficit hyperactivity disorder, unspecified type.

 

The ADHD diagnosis may not be established at the time of the initial physician office visit. Therefore, it may take two or more visits before the diagnosis is confirmed or ruled out.

ICD-10-CM outpatient coding guidelines specify not to assign a diagnosis code when documented as rule out, working diagnosis or other similar terms indicating uncertainty.

 

Instead, the outpatient coding guidelines instruct to code the condition(s) to the highest degree of certainty for that encounter/visit, requiring the use of codes that describe symptoms, signs or another reason for the visit.

 

History codes (categories Z80 to Z87) may be used as secondary codes if the historical condition or family history impacts current care or influences treatment. Personal and family history of ADHD has an impact on the clinical assessment of an individual for this disorder; the ICD-10-CM codes to report the history of ADHD in an individual include:

  • 59: Personal history of other mental and behavioral disorders.
  • 8: Family history of other mental and behavioral disorders.

 

Psychosocial circumstances

ICD-10-CM provides codes for behaviors that are not classified as behavioral disorders, such as:

  • 840: Attention and concentration deficit
  • 83: Excessive crying of child, adolescent, or adult
  • 87: Impulsiveness
  • 81: Obsessive-compulsive behavior.

 

Resources:

1 American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition (DSM-5)

 

NYE-NU-0310-21 April 2021

 

State & FederalMedicaidJune 30, 2021

What Matters Most: Improving the Patient Experience

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

What Matters Most: Improving the Patient Experience is an online course for providers and office staff that addresses gaps in care and offers approaches to communication with patients. 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.

 

NYE-NU-0315-21 April 2021

 

State & FederalMedicaidJune 30, 2021

Resources to support your diverse patient panel

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

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

Here is an overview of the cultural competency resources available on our provider website.

  • Cultural Competency and Patient Engagement includes:
    • The impact of culture and cultural competency on healthcare.
    • A cultural competency continuum, which can help providers assess their level of cultural competency.
    • Disability competency and information on the Americans with Disabilities Act (ADA).
  • Caring for Diverse Populations Toolkit includes:
    • Comprehensive information, tools and resources to support enhanced care for diverse patients and mitigate barriers.
    • Materials that can be printed and made available for patients in provider offices.
    • Regulations and standards for cultural and linguistic services.
  • My Diverse Patients offers:
    • A comprehensive repository of resources to providers to help support the needs of diverse patients and address disparities.
    • Courses with free continuing education credit through the American Academy of Family Physicians.
    • Free accessibility from any device (for example, desktop computer, laptop, phone or tablet), no account or login required.

 

To access these resources, go to https://providerpublic.empireblue.com > Provider Training Academy > Cultural competency resources.

 

In addition, providers can access Stronger Together, which offers free resources to support the diverse health needs of all people where they live, learn, work and play. These resources were created by our parent company in collaboration with national organizations and are available for you to share with your patients and communities.



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% or 1,000 individuals in New York.1

 

Prevalent non-English languages in NY:

  • Arabic
  • Chinese Includes Mandarin, Cantonese
  • Korean
  • Russian
  • Spanish

 

Language support services

As a reminder, Empire provides language assistance services for our members with limited English proficiency (LEP) or hearing, speech, or visual impairments. Please see the provider manual for details on what is available and how to access resources. In addition, the cultural competency resources shared above provide guidance on communicating and serving diverse populations effectively.

 

1 Source: American Community Survey, 2019 American Community Survey 1-Year Estimates, Table B16001, generated 10/04/2020.

 

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State & FederalMedicaidJune 30, 2021

Keep up with Medicaid news

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

State & FederalMedicare AdvantageJune 30, 2021

Attention facilities: Sending admission, discharge and transfer data to Empire results in improved care management for patients

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.

 

CMS issued an Interoperability and Patient Access Policy to reduce the burden of certain administrative processes. The CMS policy requires providers to implement application programming interfaces (APIs) to improve the electronic exchange of healthcare data between patient, provider and payer. The policy reiterates that in partnership with the Office of the National Coordinator for Health Information (ONC), CMS identified Health Level 7® (HL7) as the foundational standard to support data exchange via secure API. Implementation of this CMS mandate is expected by July 1, 2021.

 

The Clinical Data Acquisition Group for Empire integrates admission, discharge and transfer (ADT) data from facility providers, health information exchanges and third-party aggregators. ADT data exchange helps Empire:

  • Better support members with care coordination and discharge planning — leading to healthier outcomes for our members, your patients.
  • Proactively manage care transitions to avoid waste.
  • Close care gaps and educate members about appropriate care settings.

 

Empire would like to digitally exchange HL7 ADT messaging data for our members using secure data collection and transmission capabilities currently in use by facility systems. Facilities with network connections through vendors or health information exchanges can integrate ADT data with Empire through these channels as well. Near real-time HL7 ADT messaging data — or at least within 24 hours of admission, discharge or transfer — enables Empire to most effectively manage care transitions.

 

Email the Clinical Data and Analytics team at ADT_Intake@Anthem.com to get started today.

 

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State & FederalMedicare AdvantageJune 30, 2021

Let’s Vaccinate

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Help increase your vaccination rates and close gaps-in-care with these tools and strategies

Healthcare providers are seen as trusted sources of medical information and are in a unique position to improve lives and community health. Research shows that a strong vaccination recommendation from a provider is the greatest motivator for people of all ages to vaccinate themselves and their family members against serious infectious diseases.

 

Let’s Vaccinate offers providers tools and strategies to aid in vaccinating people of all ages. This website will help your practice:

  • Address disparities for vaccine-preventable diseases.
  • Identify and fill workflow gaps, including assessing vaccination status, enhancing vaccine, communications, providing vaccine education, and improving vaccine management and administration in your office.
  • Access up-to-date guidance from the Centers for Disease Control and Prevention (CDC) for vaccines.
  • Connect with your state immunization program, local immunization coalition, or other vaccine advocates in your community to collaborate.

 

Keeping all patients healthy and safe requires the support and collaboration of the entire healthcare industry. So, together, let’s vaccinate.

 

Let’s Vaccinate is a collaboration of Anthem, Inc., Pfizer Inc., and Vaccinate Your Family.

 

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State & FederalMedicare AdvantageJune 30, 2021

New reimbursement policy: Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing (Effective 10/01/21)

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

Empire BlueCross BlueShield does not allow pass-through billing for lab services. Claims appended with Modifier 90 and an office place of service will be denied unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.

 

Reimbursement will be made directly to the laboratory that performed the clinical diagnostic laboratory test based on 100% of the applicable fee schedule or contracted/negotiated rate. 

 

Modifier 90 is defined as when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified healthcare professional. The procedure may be identified by adding Modifier 90 to the usual procedure number.

 

For additional information, please review the Modifier 90: Reference (Outside) Laboratory and Pass-Through Billing reimbursement policy at www.empireblue.com/medicareprovider.

 

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State & FederalMedicare AdvantageJune 30, 2021

Prior authorization requirement changes effective October 1, 2021, for codes A0426 and A0428

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

On October 1, 2021, prior authorization (PA) requirements will change for A0426 and A0428 covered by Empire BlueCross BlueShield. Federal and state law, as well as state contract language and CMS guidelines, including definitions and specific contract provisions/exclusions, take precedence over these precertification rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims.

 

PA requirements will be added for the following codes:

  • A0426 — ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
  • A0428 — ambulance service, basic life support, nonemergency transport (BLS)

 

Not all PA requirements are listed here. Detailed PA requirements are available to contracted providers by accessing the provider self-service tool on the Availity* Portal at https://www.availity.com or on the provider website at https://www.empireblue.com/medicareprovider > Login. Contracted and noncontracted providers unable to access Availity can call the Provider Services number located on the back of their patient’s member ID card for PA requirements.

 

* Availity, LLC is an independent company providing administrative support services on behalf of Empire BlueCross BlueShield.

 

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State & FederalMedicare AdvantageJune 30, 2021

Medical drug benefit Clinical Criteria updates

Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem.

On March 25, 2021, and April 8, 2021, the Pharmacy and Therapeutics (P&T) Committee approved the following Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield. These policies were developed, revised, or reviewed to support clinical coding edits.

 

Visit Clinical Criteria to search for specific policies. If you have questions or would like additional information, use this email.

 

Please see the explanation/definition for each category of Clinical Criteria below:

  • New: newly published criteria
  • Revised: addition or removal of medical necessity requirements, new document number
  • Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive

 

Please share this notice with other members of your practice and office staff.

 

Note: The Clinical Criteria listed below applies only to the medical drug benefits contained within the member’s medical policy. This does not apply to pharmacy services.

 

Effective date

Document number

Clinical Criteria title

New or revised

July 16, 2021

ING-CC-0195*

Abecma (idecabtagene vicleucel)

New

July 16, 2021

ING-CC-0191*

Pepaxto (melphalan flufenamide; melflufen)

New

July 16, 2021

ING-CC-0192*

Cosela (trilaciclib)

New

July 16, 2021

ING-CC-0193*

Evkeeza (evinacumab)

New

July 16, 2021

ING-CC-0194*

Cabenuva (cabotegravir extended-release; rilpivirine extended-release) Injection

New

 

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