 Provider News New YorkJune 2022 NewsletterBeginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning in June 2022, Empire BlueCross BlueShield (“Empire”) will implement new processes for providers to validate the information we have in our online provider directories.
Individual providers
Empire is partnering with CAQH to assist us in validation for individual providers. Providers will receive communications from CAQH asking them to register for CAQH ProView®, the online provider data-collection service, where providers can review and verify their information, as well as provide updates that may be needed.
Facilities and groups
Empire is also partnering with First Source to assist us in validating information for facilities and groups. A file will be sent to providers with the information we have in our systems. We are asking that providers review this file, validate correct information and provide updates as needed.
If you have questions, please contact Provider Services.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material adverse change (MAC)
Effective with dates of service on or after September 1, 2022, Empire BlueCross BlueShield (“Empire”) will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.
Prior to payment, Empire will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Empire will reimburse using CPT code 99211.
Professional providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.
If you have questions on this program, contact your Provider Experience representative.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Register today for the Exploring the Intersection of Race and Disability forum hosted by Empire BlueCross BlueShield (“Empire”) and Motivo* for Empire providers on June 22, 2022.
Empire is committed to making healthcare simpler and reducing health disparities. We believe that open discussions about the disability experience for people of and reducing implicit bias, is critical to improving the health and wellbeing of all Americans and the communities in which we live and serve.
Please join us to hear from a diverse panel of experienced professionals from Motivo and Empire about the intersection of disability and race on our health and wellbeing. This forum will explore ways we can advance equity in healthcare, demonstrate cultural humility, address and deconstruct bias, have difficult and productive conversations, learn about valuable resources, and increase the diversity of the healthcare profession.
Wednesday, June 22, 2022
4:00 p.m. to 5:30 p.m. ET
Please register for this event by June 22, 2022
Register today!
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. One in every 10 Americans have diabetes, but one in every five don’t know they have it. This makes annual testing important to those who have symptoms. For those patients who are diagnosed, testing is vitally important to reducing serious health complications and the costs associated with them. It isn’t always easy to help patients understand the need for annual testing. The Centers for Disease Control and Prevention has resources you can use in your practice to educate, inform, and hopefully motivate your patients. Visit their website cdc.gov and use their Health Care Providers section to access patient education programs, prevention toolkits and more.
Measure up
Comprehensive Diabetes Care (CDC): This HEDIS® measure evaluates Empire BlueCross BlueShield members aged 18 to 75 years with type 1 or type 2 diabetes. Each year, members with type 1 or type 2 diabetes should have:
- Hemoglobin A1c (HbA1c) testing - HbA1c control (< 8%)
- Eye exam (retinal) performed
- Evaluation for kidney disease
- BP control (< 140/90 mm Hg)
|
Code type
|
Description
|
Code
|
|
ICD-10
|
Type 1 diabetes mellitus without complications
|
E10.9
|
|
ICD-10
|
Type 2 diabetes mellitus without complications
|
E11.9
|
|
ICD-10
|
Other specified diabetes mellitus without complications
|
E13.9
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Consolidated Appropriations Act (CAA), effective January 1, 2022, contains a provision that requires online provider directory information be reviewed and updated (if needed) at least every 90 days. Please review your demographic information in our online provider directories to ensure members and fellow providers can reach you.
Submit your updates by using our online Provider Maintenance Form. Update options include:
- add/change an address location
- name change
- tax ID changes
- provider leaving a group or a single location
- phone/fax number changes
- closing a practice location
You will receive an email to acknowledge your submitted Provider Maintenance Form. Visit the Provider Maintenance Form landing page for complete instructions.
Thank you for doing your part to help keep our online provider directories up to date.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In its efforts to improve the health of humanity, Empire BlueCross BlueShield (“Empire”) has made a long-term commitment to reducing morbidity and mortality associated with substance use disorder. In recent years, with a focus on primary and secondary prevention, we’ve seen significant reductions in the use of inappropriate opioid prescriptions for acute and chronic pain as well as the promotion of and increased use of safe alternatives for pain management. Similarly, Empire has been a leader in increasing access to evidence-based treatment for substance use disorders including medication for addiction treatment (MAT).
Unfortunately, the COVID-19 pandemic has hindered the nation’s progress as evidenced by a 30% rise in deaths from overdose that the nation has experienced with the majority being from opioids (CDC). The impact on overdose rates from the pandemic requires that we also increase our efforts at preventing deaths from opioid overdose. Specifically, there is a need/opportunity to work collaboratively with our partners in the community to increase access to the opioid overdose reversal drug naloxone (aka “Narcan”). Empire’s internal claims data from the second quarter of 2021 shows that approximately 20% of members experiencing a non-fatal opioid overdose are starting and continuing with medication for opioid use disorder (MOUD) which can include buprenorphine, methadone or naltrexone. However, only 7% of these members have evidence of filling a prescription for naloxone. These rates have improved from a 2015 baseline of approximately 1%, but we have significant room for improvement.
What can we do to address this?
First, be an advocate for destigmatizing substance use disorders by supporting efforts to improve access to MOUD and harm reduction strategies including the use naloxone. We can learn more at www.Shatterproof.org, which is an organization that Empire has historically supported.
Second, educate your patients about substance use disorders including how to spot them in a loved one, and how to support them when considering change. Visit https://www.samhsa.gov/find-help/recovery for more information.
Third, learn more about the life saving opioid overdose reversal drug naloxone including how to obtain it, and how to administer it. See www.getnaloxonenow.org for more information.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
This communication applies to the Commercial and Medicare Advantage programs from
Empire BlueCross BlueShield (Empire).
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health advanced imaging clinical appropriateness guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by Guideline
Imaging of the Spine:
- Perioperative and periprocedural imaging – added requirement for initial evaluation with radiographs
Imaging of the Extremities:
- Trauma – added CT as an alternative to MRI for tibial plateau fracture; added indication for evaluation of supracondylar fracture
- Rotator cuff tear – combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
- Shoulder arthroplasty – modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
- Perioperative imaging – excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty
Vascular Imaging:
- Stenosis or occlusion, extracranial carotid arteries: - New indications for post neck irradiation, incidental carotid calcification scenarios.
- Stroke/TIA, extracranial evaluation - Subacute stroke/TIA: CTA/MRA Neck allowed without prerequisite ultrasound (US), in alignment with 2021 AHA/ASA guidelines.
- Chronic stroke/TIA - New indication; modality approach by circulation presentation.
- Pulmonary Embolism - Removal of nondiagnostic CXR requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID infection, etc).
- Imaging study modality and/or site expansion - Pulsatile Tinnitus, Acute Aortic Syndrome, Abdominal venous thrombosis
- Stenosis or occlusion, extracranial carotid arteries - Post-revascularization scenario aligned with SVS guidelines to allow annual surveillance regardless of residual stenosis.
- Aneurysm of the abdominal aorta or iliac arteries - Management/surveillance scenarios aligned with SVS guidelines.
- Upper or Lower Extremity Peripheral arterial disease (PAD):
- Suspected PAD without physiologic testing (including exercise testing) not indicated
- New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com . Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health musculoskeletal clinical appropriateness guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
Updates by guideline
Spine surgery:
- Lumbar disc arthroplasty – add indication for 2-level lumbar disc arthroplasty when using a 2-level FDA-approved implant
- Lumbar discectomy – remove exclusion for annular closure devices (note: medical necessity of the implant is determined by health plan medical policy)
- Lumbar fusion – remove exclusion for anterior lumbar interbody fusion for indirect lumbar decompression in the absence of instability
- Cervical decompression with or without Fusion – add criteria for when revision or replacement may be medically necessary
- Cervical disc arthroplasty – add criteria for when revision or replacement may be medically necessary
- Two-level cervical disc arthroplasty – add indication for second level arthroplasty when prior arthroplasty already performed
- Lumbar disc arthroplasty – add requirement to manage underlying psychiatric disorder; add contraindications including prior fusion, poorly managed psychiatric disorder, chronic radiculopathy; add exclusion for prior lumbar fusion
- Scheurmann’s kyphosis – removed “associated neurological deficits” as a clinical consideration
- Scoliosis – expand indication to include thoracic for progressive adolescent idiopathic scoliosis; increased Cobb angle for skeletally mature patients to greater than 50 degrees
- Spinal stenosis – require surgeon’s interpretation of flexion-extension lateral spine x-ray documented in the medical record; added indications for recurrent stenosis, adjacent-level stenosis after a prior fusion, and planned indirect decompression via anterior approach decompression via anterior approach
Joint surgery:
- Total shoulder arthroplasty – add fracture indication for total shoulder arthroplasty (although reverse total shoulder arthroplasty is preferred) to align with AAOS feedback
- Total shoulder arthroplasty – add exception for Kellgren-Lawrence grade 4 to be consistent with total knee and total hip arthroplasty
- Hemiarthroplasty – added indications for hemiarthroplasty for glenohumeral arthritis with irreparable rotator cuff and for malignancy involving the glenohumeral joint or surrounding soft tissue
- Reverse shoulder arthroplasty – add indication when glenoid bone stock inadequate to support anatomic glenoid prosthesis
- Labrum repair – remove requirement that MRI-demonstrated SLAP lesion is traumatic in nature
- Adhesive capsulitis – match requirements in knee arthroscopy; reduce timeframe of conservative management to 6 weeks post-surgery for lysis of adhesions/capsular release and MUA
- Total knee arthroplasty – add patellofemoral osteoarthritis as an indication for total knee arthroplasty
- Knee arthroscopy – new indication for abrasion arthroplasty/microfracture
- Knee/arthroscopically assisted lysis of adhesions – remove 12-week post-surgery requirement
- Knee/manipulation under anesthesia – remove 12-week post-surgery requirement
- Treatment of osteochondral defects – remove BMI 35 or less from patient selection criteria
- Autologous chondrocyte implantation – Added contraindications from MACI package insert, including severe osteoarthritis, inflammatory joint disease, knee surgery other than biopsy or MACI preparation, and inability to cooperate with postoperative rehab program
Small joint surgery:
- Hallux rigidus – add criteria for select implant arthroplasties in great toe; remove exclusion for percutaneous osteotomy
- Hallux valgus/bunionette – remove exclusion for implant arthroplasties
- Lesser toe deformities – remove exclusions for implant arthroplasties and intramedullary fixation devices
- First metatarsophalangeal joint arthrodesis – remove requirement for 6 months of symptoms
- First metatarsophalangeal joint arthroplasty – new indication
- Hallux rigidus/exclusions – clarified specific types of excluded implants; excluded metatarsophalangeal joint arthroplasties for any other indications; excluded peripheral neuropathy/Charcot joint
Sacroiliac joint (SU) fusion:
- Expand indication to include any FDA-approved minimally invasive/percutaneous SI joint fusion device with fixation
- Require a trial of at least one therapeutic intra-articular SI joint injection
- New criteria for revision minimally invasive SI joint fusion
- Add exclusion for posterior (dorsal) minimally invasive SI joint fusion procedures using only bone grafts and no internal fixation device
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number: 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com . Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health sleep disorder management clinical appropriateness guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable health care services.
- Established sleep disorder (OSA or other) – follow-up laboratory studies – added indication for one follow-up in-lab sleep study as appropriate following insertion of a hypoglossal nerve stimulator
- Multiple Sleep Latency Testing (MSLT) and/or Maintenance of Wakefulness Testing (MWT) – new indication for MWT in occupational safety evaluation
- Management of OSA using Oral Appliances (OA) – limit guideline for oral appliance use to patients 16 years and older
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortalSM directly at providerportal.com
- Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
- Access AIM via the Availity Web Portal at availity.com
- Call the AIM Contact Center toll-free number 1-877-430-2288, Monday–Friday, 8:00 a.m.–6:00 p.m. ET.
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com . Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective June 1, 2022, the Blue Cross Blue Shield Service Benefit Plan, aka Federal Employee Program (FEP), will be changing the process for responses to third-party requests for correspondence for claim processing. Currently, Empire BlueCross BlueShield (“Empire”) sends correspondence to the third-party biller who requested the information. Effective June 1, 2022, responses to correspondence requests received from third-party billers will be mailed to the servicing provider office to align with internal Empire policy directives.
Questions can be directed to the FEP Customer Service team at 1-800-522-5566.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Material Adverse Change (MAC)
Specialty pharmacy updates for Empire BlueCross BlueShield (“Empire”) are listed below.
Prior authorization clinical review of non-oncology use of specialty pharmacy drugs is managed by Empire’s medical specialty drug review team. Review of specialty pharmacy drugs for oncology use is managed by AIM Specialty Health® (AIM), a separate company.
Important to note: Currently, your patients may be receiving these medications without prior authorization. As of the effective date below, you may be required to request prior authorization review for your patients’ continued use of these medications.
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.
Prior authorization updates
Effective for dates of service on and after September 1, 2022, the following specialty pharmacy codes from current or new clinical criteria documents will be included in our prior authorization review process.
Access our Clinical Criteria to view the complete information for these prior authorization updates.
|
Clinical Criteria
|
Drug
|
HCPCS or CPT Code(s)
|
|
ING-CC-0214
|
Carvykti (ciltacabtagene autoleucel)
|
C9399
J3490
J3590
|
|
ING-CC-0200
|
Aduhelm (aducanumab-avwa)
|
J0172
|
Note: Prior authorization requests for certain medications may require additional documentation to determine medical necessity.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. This communication applies to the Commercial and Medicaid programs from Empire.
Evaluation and management services for COVID-19 testing - professional
Effective with dates of service on or after September 1, 2022, Empire will facilitate review of selected claims for COVID-19 visits reported with Evaluation and Management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.
Prior to payment, Empire will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Empire will reimburse using CPT code 99211.
Professional providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.
If you have questions on this program, contact Provider Services at 1-800-450-8753 for Medicaid Managed Care or the number on the back of your patient’s member ID card for Commercial.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire BlueCross BlueShield HealthPlus (Empire) is migrating to InterQual medical necessity criteria for inpatient, partial, and intensive outpatient mental health authorizations, effective September 1, 2022. We are pleased to share that Empire will be using an integrated version of InterQual that functions in concert with the OMH Dimensions of Health. Empire will be outreaching in-network providers to initiate quarterly meetings to introduce and further discuss to allow for a smooth transition for our members and providers alike.
The InterQual criteria transition will allow us to initiate a targeted focus on high-risk members, integrate social drivers of health, increase provider collaboration, and most importantly improve member outcomes.
If you have questions about this communication or need assistance with any other item, visit the Contact Us section at the bottom of our provider website (https://providerpublic.empireblue.com) for up-to-date contact information or call Provider Services at 800-450-8753.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit
https://www.empireblue.com/provider/policies/clinical-guidelines/search.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *CG-LAB-20 — Thyroid Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
- *CG-LAB-21 — Serum Iron Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
- *LAB.00043 — Immune Biomarker Tests for Cancer:
- Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
- *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
- Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
- *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
- The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
- Endometrial receptivity analysis
- Sperm-capacitation test
- Sperm deoxyribonucleic acid (DNA) fragmentation test
- Sperm penetration assay
- Uterine natural killer (uNK) cells test
- *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
- Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
- Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
- Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
- *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
- Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
- *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
- Revised Position Statement to include the prevention of lymphedema.
- *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
- The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
- *TRANS.00038 — Thymus Tissue Transplantation:
- Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.
Medical Policies
On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield HealthPlus (Empire). These guidelines take effect June 8, 2022.
|
Publish date
|
Medical Policy number
|
Medical Policy title
|
New or revised
|
|
04/13/2022
|
*LAB.00043
|
Immune Biomarker Tests for Cancer
|
New
|
|
04/13/2022
|
*LAB.00044
|
Saliva-based Testing to Determine
Drug-Metabolizer Status
|
New
|
|
04/13/2022
|
*LAB.00045
|
Selected Tests for the Evaluation and Management of Infertility
|
New
|
|
04/13/2022
|
*LAB.00046
|
Testing for Biochemical Markers for Alzheimer’s Disease
|
New
|
|
04/13/2022
|
*RAD.00067
|
Quantitative Ultrasound for Tissue Characterization
|
New
|
|
04/13/2022
|
*SURG.00160
|
Implanted Port Delivery Systems to Treat Ocular Disease
|
New
|
|
03/25/2022
|
*TRANS.00038
|
Thymus Tissue Transplantation
|
New
|
|
04/13/2022
|
GENE.00052
|
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
|
Revised
|
|
04/1/2022
|
SURG.00011
|
Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised
|
|
02/24/2022
|
SURG.00036
|
Fetal Surgery for Prenatally Diagnosed Malformations
|
Revised
|
|
04/13/2022
|
SURG.00096
|
Surgical and Ablative Treatments for Chronic Headaches
|
Revised
|
|
04/13/2022
|
*SURG.00154
|
Microsurgical Procedures for the Prevention or Treatment of Lymphedema
|
Revised
|
Clinical UM Guidelines
On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines adopted by the medical operations committee for our members on March 24, 2022. These guidelines take effect June 8, 2022.
|
Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or revised
|
|
04/13/2022
|
*CG-LAB-20
|
Thyroid Testing
|
New
|
|
04/13/2022
|
*CG-LAB-21
|
Serum Iron Testing
|
New
|
|
04/13/2022
|
CG-ANC-03
|
Acupuncture
|
Revised
|
|
04/13/2022
|
CG-GENE-14
|
Gene Mutation Testing for Cancer Susceptibility and Management
|
Revised
|
|
04/13/2022
|
CG-MED-73
|
Hyperbaric Oxygen Therapy (Systemic/Topical)
|
Revised
|
|
04/13/2022
|
CG-SURG-36
|
Adenoidectomy
|
Revised
|
|
02/24/2022
|
CG-SURG-86
|
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
|
Revised
|
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 from Empire.
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.
Updates by Guideline
Imaging of the spine
- Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs
Imaging of the extremities
- Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture
- Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
- Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
- Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty
Vascular imaging
- Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios
- Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines
- Chronic stroke/TIA – New indication; modality approach by circulation presentation
- Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
- Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
- Stenosis or occlusion, extracranial carotid arteries – Post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
- Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
- Upper or lower extremity peripheral arterial disease (PAD):
- Suspected PAD without physiologic testing (including exercise testing) not indicated
- New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortal℠ directly at https://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 Monday through Friday from 8 a.m. to
8 p.m. ET:
- Medicaid: 855-574-6481
- Medicare: 866-745-1784
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Evaluation and management services for COVID-19 testing - professional
Effective with dates of service on or after September 1, 2022, Empire BlueCross BlueShield (Empire) will facilitate review of selected claims for COVID-19 visits reported with evaluation and management (E/M) services submitted by professional providers to align with CMS reporting guidelines. When the purpose of the visit is for COVID-19 testing only, reimbursement for CPT® code 99211 (office or other outpatient visit) is allowed when billed with place of service office (11), mobile unit (15), walk-in retail health clinic (17), or urgent care facility (20). Claims for exposure only may be affected. Professional providers are encouraged to code their claims to the highest level of specificity in accordance with ICD-10 coding guidelines.
Prior to payment, Empire will review the selected claims to determine, in accordance with correct coding requirements and/or reimbursement policy as applicable, whether the E/M code level submitted is appropriate for the COVID-19 visit reported. If the visit is determined to be solely for the purpose of COVID-19 testing, Empire will reimburse using CPT code 99211.
Professional providers that believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service will be able to follow the Claims Payment Dispute process (including submission of such documentation with the dispute) as outlined in the provider manual.
If you have questions on this program, contact your Provider Experience representative.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On November 19, 2021, January 4, 2022, and February 25, 2022, 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
|
|
June 9, 2022
|
*ING-CC-0211
|
Kimmtrak (tebentafusp-tebn)
|
New
|
|
June 9, 2022
|
*ING-CC-0210
|
Enjaymo (sutimlimab-jome)
|
New
|
|
June 9, 2022
|
*ING-CC-0213
|
Voxzogo (vosoritide)
|
New
|
|
June 9, 2022
|
*ING-CC-0212
|
Tezspire (tezepelumab-ekko)
|
New
|
|
June 9, 2022
|
*ING-CC-0086
|
Spravato (esketamine) Nasal Spray
|
Revised
|
|
June 9, 2022
|
ING-CC-0157
|
Padcev (enfortumab vedotin)
|
Revised
|
|
June 9, 2022
|
ING-CC-0125
|
Opdivo (nivolumab)
|
Revised
|
|
June 9, 2022
|
ING-CC-0119
|
Yervoy (ipilimumab)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0099
|
Abraxane (paclitaxel, protein bound)
|
Revised
|
|
June 9, 2022
|
ING-CC-0120
|
Kyprolis (carfilzomib)
|
Revised
|
|
June 9, 2022
|
ING-CC-0126
|
Blincyto (blinatumomab)
|
Revised
|
|
June 9, 2022
|
ING-CC-0129
|
Bavencio (avelumab)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0090
|
Ixempra (ixabepilone)
|
Revised
|
|
June 9, 2022
|
ING-CC-0110
|
Perjeta (pertuzumab)
|
Revised
|
|
June 9, 2022
|
ING-CC-0115
|
Kadcyla (ado-trastuzumab)
|
Revised
|
|
June 9, 2022
|
ING-CC-0108
|
Halaven (eribulin)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0033
|
Xolair (omalizumab)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0043
|
Monoclonal Antibodies to Interleukin-5
|
Revised
|
|
June 9, 2022
|
ING-CC-0038
|
Human Parathyroid Hormone Agents
|
Revised
|
|
June 9, 2022
|
*ING-CC-0186
|
Margenza (margetuximab-cmkb)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0124
|
Keytruda (pembrolizumab)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0078
|
Orencia (abatacept)
|
Revised
|
|
June 9, 2022
|
ING-CC-0050
|
Monoclonal Antibodies to Interleukin-23
|
Revised
|
|
June 9, 2022
|
ING-CC-0042
|
Monoclonal Antibodies to Interleukin-17
|
Revised
|
|
June 9, 2022
|
*ING-CC-0029
|
Dupixent (dupilumab)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0208
|
Adbry (tralokinumab)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0209
|
Leqvio (inclisiran)
|
Revised
|
|
June 9, 2022
|
*ING-CC-0166
|
Trastuzumab Agents
|
Revised
|
|
June 9, 2022
|
*ING-CC-0107
|
Bevacizumab for Non-ophthalmologic Indications
|
Revised
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The Medical Policies, Clinical Utilization Management (UM) Guidelines and Third-Party Criteria below were developed and/or revised to support clinical coding edits. Note, several policies and guidelines were revised to provide clarification only and are not included. Existing precertification requirements have not changed.
Please share this notice with other members of your practice and office staff.
To view a guideline, visit https://www.empireblue.com/provider/policies/clinical-guidelines/search.
Notes/updates:
Updates marked with an asterisk (*) notate that the criteria may be perceived as more restrictive.
- *CG-LAB-20 — Thyroid Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for thyroid testing.
- *CG-LAB-21 — Serum Iron Testing:
- Outlines the Medically Necessary and Not Medically Necessary criteria for serum iron testing.
- *LAB.00043 — Immune Biomarker Tests for Cancer:
- Oncologic immune biomarker tests are considered Investigational and Not Medically Necessary for all indications.
- *LAB.00044 — Saliva-Based Testing to Determine Drug-Metabolizer Status:
- Saliva-based testing to determine drug-metabolizer status is considered Investigational and Not Medically Necessary for all indications.
- *LAB.00045 — Selected Tests for the Evaluation and Management of Infertility:
- The following tests or procedures are considered Investigational and Not Medically Necessary for diagnosing or managing infertility:
- Endometrial receptivity analysis
- Sperm-capacitation test
- Sperm deoxyribonucleic acid (DNA) fragmentation test
- Sperm penetration assay
- Uterine natural killer (uNK) cells test
- *LAB.00046 — Testing for Biochemical Markers for Alzheimer’s Disease:
- Measurements of biochemical markers (including but not limited to tau protein, AB-42, neural thread protein) is considered Investigational and Not Medically Necessary as a diagnostic technique for individuals with symptoms suggestive of Alzheimer’s disease.
- Measurements of biochemical markers as a screening technique in asymptomatic individuals with or without a family history of Alzheimer’s disease is considered Investigational and Not Medically Necessary.
- Moved content related to biomarker testing for Alzheimer’s disease from GENE.00003 Biochemical Markers for the Diagnosis and Screening of Alzheimer’s Disease to this document.
- *RAD.00067 — Quantitative Ultrasound for Tissue Characterization:
- Quantitative ultrasound for tissue characterization is considered Investigational and Not Medically Necessary for all indications.
- *SURG.00154 — Microsurgical Procedures for the Prevention or Treatment of Lymphedema:
- Revised Position Statement to include the prevention of lymphedema.
- *SURG.00160 — Implanted Port Delivery Systems to Treat Ocular Disease:
- The use of a port delivery system to treat ocular disease is considered Investigational and Not Medically Necessary for all indications.
- *TRANS.00038 — Thymus Tissue Transplantation:
- Outlines the Medically Necessary and Investigational and Not Medically Necessary criteria for allogeneic processed thymus tissue.
Medical Policies
On February 17, 2022, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies applicable to Empire BlueCross BlueShield (Empire). These guidelines take effect June 4, 2022.
|
Publish date
|
Medical Policy number
|
Medical Policy title
|
New or revised
|
|
04/13/2022
|
*LAB.00043
|
Immune Biomarker Tests for Cancer
|
New
|
|
04/13/2022
|
*LAB.00044
|
Saliva-based Testing to Determine Drug-Metabolizer Status
|
New
|
|
04/13/2022
|
*LAB.00045
|
Selected Tests for the Evaluation and Management of Infertility
|
New
|
|
04/13/2022
|
*LAB.00046
|
Testing for Biochemical Markers for Alzheimer’s Disease
|
New
|
|
04/13/2022
|
*RAD.00067
|
Quantitative Ultrasound for Tissue Characterization
|
New
|
|
04/13/2022
|
*SURG.00160
|
Implanted Port Delivery Systems to Treat Ocular Disease
|
New
|
|
03/25/2022
|
*TRANS.00038
|
Thymus Tissue Transplantation
|
New
|
|
04/13/2022
|
GENE.00052
|
Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling
|
Revised
|
|
04/1/2022
|
SURG.00011
|
Allogeneic, Xenographic, Synthetic, Bioengineered, and Composite Products for Wound Healing and Soft Tissue Grafting
|
Revised
|
|
02/24/2022
|
SURG.00036
|
Fetal Surgery for Prenatally Diagnosed Malformations
|
Revised
|
|
04/13/2022
|
SURG.00096
|
Surgical and Ablative Treatments for Chronic Headaches
|
Revised
|
|
04/13/2022
|
*SURG.00154
|
Microsurgical Procedures for the Prevention or Treatment of Lymphedema
|
Revised
|
Clinical UM Guidelines
On February 17, 2022, the MPTAC approved the following Clinical UM Guidelines applicable to Empire. These guidelines adopted by the medical operations committee for our members on March 24, 2022. These guidelines take effect June 4, 2022.
|
Publish date
|
Clinical UM Guideline number
|
Clinical UM Guideline title
|
New or revised
|
|
04/13/2022
|
*CG-LAB-20
|
Thyroid Testing
|
New
|
|
04/13/2022
|
*CG-LAB-21
|
Serum Iron Testing
|
New
|
|
04/13/2022
|
CG-ANC-03
|
Acupuncture
|
Revised
|
|
04/13/2022
|
CG-GENE-14
|
Gene Mutation Testing for Cancer Susceptibility and Management
|
Revised
|
|
04/13/2022
|
CG-MED-73
|
Hyperbaric Oxygen Therapy (Systemic/Topical)
|
Revised
|
|
04/13/2022
|
CG-SURG-36
|
Adenoidectomy
|
Revised
|
|
02/24/2022
|
CG-SURG-86
|
Endovascular/Endoluminal Repair of Aortic Aneurysms, Aortoiliac Disease, Aortic Dissection and Aortic Transection
|
Revised
|
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 from Empire.
Effective for dates of service on and after September 11, 2022, the following updates will apply to the AIM Specialty Health®* (AIM) Advanced Imaging Clinical Appropriateness Guidelines. As part of the AIM guideline annual review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.
Updates by Guideline
Imaging of the spine
- Perioperative and periprocedural imaging – Added requirement for initial evaluation with radiographs
Imaging of the extremities
- Trauma – Added computerized tomography (CT) scan as an alternative to magnetic resonance imaging (MRI) for tibial plateau fracture; added indication for evaluation of supracondylar fracture
- Rotator cuff tear – Combined acute and chronic rotator cuff tear criteria; standardized conservative management duration to 6 weeks
- Shoulder arthroplasty – Modified language to clarify intent regarding limited scenarios where advanced imaging is indicated for total shoulder arthroplasty
- Perioperative imaging – Excluded robotic-assisted hip arthroplasty as robotic-assisted surgery in general does not provide net benefit over conventional arthroplasty
Vascular imaging
- Stenosis or occlusion, extracranial carotid arteries – New indications for post neck irradiation, incidental carotid calcification scenarios
- Stroke/Transient ischemic attack (TIA), extracranial evaluation – Subacute stroke/TIA; computed tomography angiography (CTA)/magnetic resonance angiography (MRA) neck allowed without prerequisite ultrasound (US), in alignment with 2021 American Heart Association (AHA)/American Stroke Association (ASA) guidelines
- Chronic stroke/TIA – New indication; modality approach by circulation presentation
- Pulmonary embolism – Removal of nondiagnostic chest radiograph (CXR) requirement (lower threshold for elevated D-dimer scenarios, thrombosis related to COVID-19 infection, etc.)
- Imaging study modality and/or site expansion – Pulsatile tinnitus, acute aortic syndrome, abdominal venous thrombosis
- Stenosis or occlusion, extracranial carotid arteries – Post-revascularization scenario aligned with the Society for Vascular Surgery (SVS) guidelines to allow annual surveillance regardless of residual stenosis.
- Aneurysm of the abdominal aorta or iliac arteries – Management/surveillance scenarios aligned with SVS guidelines.
- Upper or lower extremity peripheral arterial disease (PAD):
- Suspected PAD without physiologic testing (including exercise testing) not indicated
- New indication for Popliteal artery aneurysm US surveillance post-repair (2021 SVS guidelines)
As a reminder, ordering and servicing providers may submit prior authorization requests to AIM in one of several ways:
- Access AIM’s ProviderPortal℠ directly at https://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 Monday through Friday from 8 a.m. to 8 p.m. ET:
- Medicaid: 855-574-6481
- Medicare: 866-745-1784
For questions related to guidelines, please contact AIM via email at aim.guidelines@aimspecialtyhealth.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. |