 Provider News New YorkMay 1, 2019 May 2019 Empire Provider Newsletter Contents Medical Policy & Clinical Guidelines | Commercial | April 30, 2019 Coding Updates
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the March 2019 edition of our newsletter, we announced the exciting updates we’ve made to the Medical Attachment submission tool. As you start using the updated medical attachment tool on the Availity Portal, you will notice the following changes from the information we shared in March:
- File size – each attachment can be up to 10 MB with a maximum of 30 MB as the file size limit
- The addition of logos in your dashboard make it easy to quickly identify each payer
- The Medical Attachment tool will be retired from the Availity Portal soon, so we encourage you to start utilizing the ‘Attachment – New’ option now. Once a date has been determined for the Medical Attachment Tool retirement we will begin communication.
Other features of the updated medical attachment include:
- The ability to submit an itemized bill
- A different link tilted “Attachment – New” where you will now submit medical records when Empire has requested additional information to process a claim
- A new link on the attachment page called “Send Attachment” will allow you to start the process
- A record history of each entry provides you increased visibility of your submission
The Medical Attachment tool makes the process of submitting an electronic documentation in support of a claim, simple and streamlined. You can use your tax identification number (TIN) or your NPI to register and submit solicited (requested by Empire) medical record attachments through the Availity Portal.
NOTE: We will continue to keep you informed of upcoming changes to the ‘Attachment – New’ platform as we progress toward streamlining our electronic documentation functionality.
How to Access solicited Medical Attachments for Your Office
Availity Administrator, complete these steps:
From My Account Dashboard, select Enrollments Center>Medical Attachments Setup, follow the prompts and complete the following sections:
- Select Application>choose Medical Attachments Registration
- Provider Management>Select Organization from the drop-down. Add NPIs and/or Tax IDs (Multiples can be added separated by spaces or semi-colons)
- Assign user access by checking the box in front of the user’s name. Users may be removed by unchecking their name
Using Medical Attachments
Availity User, complete these steps:
- Log in to www.availity.com
- Select Claims and Payments > Attachments-New >Send Attachment Tab
- Complete all required fields of the form
- Attach supporting documentation
- Submit
Need Training?
To access additional training for this Availity feature: Log in and select Help & Training | Get Trained to open the Availity Learning Center (ALC) Catalog in a new browser tab. It is your dedicated ALC account. Search the Catalog by keyword (attachments) to find training demo and on-demand courses. Select Enroll to enroll for a course and then go to your Dashboard to access it any time. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a contracted provider with Empire, please remember that you are obligated when medically appropriate to refer Empire members to in-network providers. This includes physicians and all provider types including, but not limited to, ambulance transport (ground and air), ambulatory surgical centers, behavioral health services, physical medicine providers and ancillary providers. Referring to in-network providers allows members to receive the highest level of benefits under their Health Benefit Plan. As a reminder, call Empire first for prior authorization if required by the member’s policy.
Ground Ambulance Providers
You can search for participating ground providers using our online tool, Provider Finder, located at www.empireblue.com. Search parameters include distance from your location (zip code, address or county). To use the tool, go to www.empireblue.com and follow these steps in our “Find a Doctor” tool:
- Select “all plans/networks”
- Select type of coverage
- I am looking for a : “other medical services”
- Who specializes in: “ambulance companies”
- Located near: add your address, zip or county
Air Ambulance Providers
The providers listed below are participating air ambulance providers with Empire. This means that these providers have contractually agreed to accept the Empire Rate as payment in full for covered services, and they will bill members only for allowable benefit cost-share obligations when transporting members who are picked up in New York.
Some air ambulance providers choose not to participate with payers like Empire.
- These air ambulance providers may charge members rates that are much higher than the Empire contracted provider rates.
- Depending on their benefits, members who utilize non-participating air ambulance providers can be left with significant out-of-pocket expenses, which the ambulance providers and their billing agents may seek to collect.
To avoid these situations, we ask that, whenever possible, you use a participating air ambulance provider for your patients who are our members. Utilizing participating providers:
- Protects the member from balance billing for what may be excessive amounts,
- Assures the most economical use of the member’s benefits, and
- Is consistent with your contractual obligations to refer to in-network providers where available.
To schedule fixed wing or rotary wing air ambulance services, please contact for prior authorization if required by the member’s policy, then call one of the phone numbers listed below. Please have the following information ready when you call:
- Basic medical information about the patient, including the patient’s name and date of birth or age. If the service was not prior authorization with Empire, the air ambulance provider will also need to receive a full medical report from the attending facility.
- Current location of the patient, the name of the hospital or facility caring for the patient and its address (city and state).
- Location where patient is to be transported, including the name of the destination hospital/facility and address.
- Approximate transport date or time frame.
- Special equipment or care needs.
Should you have questions regarding the air ambulance network, including providers contracted for air ambulance pickups outside of New York, please contact your Network Management Consultant. To arrange air transport originating outside the U.S., U.S. Virgin Islands and Puerto Rico, call 800-810-BLUE for BCBS Global Core formerly BlueCard Worldwide
FIXED WING (AIRPLANE) PROVIDERS (HCPCS CODES: A0430 and A0435)
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Provider Name
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Phone#
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Location Address
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Web site
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Air Ambulance Specialists, Inc. dba AMR Air Ambulance
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800-424-7060
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8001 S Interport Blvd, #150, Englewood, CO 80112
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www.AMRAirAmbulance.com
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AeroCare Medical Transport Systems
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630-466-0800
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43W 752 Hwy 30 Sugar Gove IL 60554
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www.aerocare.com
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Center for Emergency Medicine of Western PA dba Stat MedEvac
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416-460-3000
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10 Alleghany County Airport, West Mifflin, PA 15122
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www.upmc.edu
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Medway Air Ambulance, Inc.
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800-233-0655
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570 Briscoe Blvd. Lawrenceville GA 30046
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www.medwayair.com
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Life Guard International, Inc. dba Flying ICU
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702-740-5952
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145 E. Reno Avenue Ste. E-7, Las Vegas, NV 89119
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www.flyingicu.com
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ROTARY WING (HELICOPTER) PROVIDERS (HCPCS CODES: A0431 & A0436)
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Provider Name
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Phone#
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Location Address
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Web site
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Air Methods (Rocky Mountain/LifeNet
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909-915-2305
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7211 South Peoria, Englewood, CO 80112-4133
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www.airmethods.com
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Center for Emergency Medicine of Western PA DBA Stat MedEvac
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416-460-3000
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10 Alleghany County Airport, West Mifflin, PA 15122
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www.upmc.edu
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As part of our commitment to provide you with the latest clinical information and educational materials, we have adopted nationally recognized medical, behavioral health and preventive health guidelines, which are available to providers on our website. The guidelines, which are used for our Quality programs, are based on reasonable, medical evidence, and are reviewed for content accuracy, current primary sources, the newest technological advances and recent medical research.
All guidelines are reviewed annually, and updated as needed. The current guidelines are available at empireblue.com/provider/ > “Find Resources in New York” > Provider Home > Health and Wellness > Practice Guidelines. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In a continuation of our CRA reporting update articles throughout 2019, Empire requests your assistance with respect to our Commercial Risk Adjustment (CRA) reporting processes.
As a reminder, there are two approaches that we take (Retrospective and Prospective) to improve risk adjustment reporting accuracy. We are focusing on performing appropriate interventions and chart reviews for patients with undocumented Hierarchical Condition Categories (HCC), to close the documentation and coding gaps that we are seeing with our members enrolled in our Affordable Care Act (ACA) compliant plans.
This month we’d like to focus on the Prospective approach, and the request to our Providers:
Empire network providers -- usually primary care physicians -- may receive letters from our vendor, Inovalon, requesting that physicians:
- schedule a comprehensive visit with patients identified to confirm or deny if previously coded or suspected diagnoses exists, and
- submit a Health Assessment documenting the previously coded or suspected diagnoses (also called a SOAP Note -- Subjective, Objective, Assessment and Plan).
Incentives for properly submitted Health Assessments (in addition to the office visit reimbursement):
- $100 submitted electronically
- $50 submitted via fax
Health Assessment requests through Inovalon
We have engaged Inovalon -- an independent company that provides secure, clinical documentation services -- to help us comply with provisions of the ACA that require us to assess members’ relative health risk level. In the coming weeks and months, Inovalon will be sending letters to providers as part of our risk adjustment cycle, asking for their help with completing health assessments for some of our members.
This year will bring a new round of assessments. As a reminder, chronic conditions must be coded every year, and we encourage you to code to the greatest level of specificity on all Empire claim submissions. If you have questions about the requests you receive, you can reach Inovalon directly at 1-866-682-6680.
Maximize your Incentive opportunity: submit electronically via Inovalon’s ePASS® tool
Join an ePASS webinar to learn how to submit a Health Assessment electronically and maximize your incentive opportunities. They are offered every Wednesday from 3:00 - 4:00pm EST. Register by sending an email to ePASSProviderRelations@inovalon.com with your name, organization, contact information and the date of the webinar you wish to attend.
- Teleconference: Dial 1-415-655-0002 (US Toll) and enter access code: 736 436 872
- WebEx: Visit https://inovalonmeet.webex.com and enter meeting number: 736 436 872
- Once you join the call, live support is available at any time by dialing *0
Alternative reporting engagement
ePASS is our preferred method for submission for the Prospective approach. However to improve engagement and collaborate with our Providers who are not submitting via ePASS, we have identified other alternatives which may be helpful and provide more flexibility with your current processes.
If you are interested in any of these alternative options, please contact our CRA Network Education Representative: Alicia.Estrada@anthem.com.
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Alternative reporting option/Description
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Availity Comprehensive Health Assessment
Availity will send a notification of members who have gaps and need assessments. The office will schedule members to be seen, at this time open gaps are displayed. Once the visit is completed, the office will complete the health assessment via Availity and the provider will review and sign off. Eligible for $100 incentive.
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EPIC Patient Assessment Form (PAF)
Providers with EPIC as their EMR system can fax the EPIC PAF to Inovalon at 1-866-682-6680 without a coversheet. Eligible for $50 incentive.
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Providers Existing Patient Assessment Form (PAF) -- Utilize providers existing EMR system and applicable PAF and fax to Inovalon at 1-866-682-6680. Must be submitted with a coversheet indicating "see attached Empire Progress Note“. Eligible for $50 incentive.
Note: Please reach out to the CRA Network Education Representative listed above for confirmation that your EMR system’s PAF is compliant.
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EPHC Providers using PCMS -- Providers participating in our Enhanced Personal Health Care (EPHC) program can use member reports from our PCMS tool within Availity to schedule members for comprehensive visits. Providers use normal gap closure through claims submission. No Health Assessment needed.
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List of Members to be scheduled -- Empire provides member report for Provider to schedule members for comprehensive visits. Providers use normal gap closure through claims submission. No Health Assessment needed.
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Allscripts Push Notifications (combine with EMR Interoperability for Chart Requests from our Retrospective approach)
Once a member is scheduled for visit, provider will get notification of outstanding gaps. Benefit: Provider is aware upfront, at the time of the visit to address chronic conditions with members and code them accurately on their claim. No Health Assessment needed.
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Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Effective August 1, 2019, Empire will upgrade to the 23rd edition of MCG care guidelines for the following modules: Inpatient & Surgical Care (ISC), General Recovery Care (GRC), Chronic Care (CC), Recovery Facility Care (RFC), Behavioral Health Care (BHC).
Goal Length of Stay (GLOS) changes for Inpatient & Surgical Care (ISC)
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Guideline
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MCG Number
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23rd Edition GLOS
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22nd Edition GLOS
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Neurology- Traumatic Brain Injury, Nonsurgical Treatment
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M-78
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Ambulatory or 2 days
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2 days
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Orthopedics-Lumbar Fusion
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S-820
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2 days postoperative
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3 days postoperative
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New Optimal Recovery Guidelines (ORGs), Common Complications and Conditions (CCC) and Level of Care (LOC) Guidelines
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Module
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Guideline
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Title
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MCG Number
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ISC
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ORG
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Anorexia Nervosa, Child or Adolescent
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P-585
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ISC
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ORG
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Substance-Related Disorders, Child or Adolescent
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P-596
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ISC
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ORG
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Left Atrial Appendage Closure, Percutaneous
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M-333
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ISC
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ORG
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Abdominal Pain, Undiagnosed, Pediatric
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P-05
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ISC
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ORG
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Craniotomy for Traumatic Brain Injury or Intracerebral Hemorrhage, Pediatric
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P-414
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ISC
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ORG
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Craniotomy, Supratentorial, Pediatric
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P-411
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ISC
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ORG
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Headaches, Pediatric
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P-185
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ISC
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ORG
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Hernia Repair (Non-Hiatal), Pediatric
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P-1305
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ISC
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ORG
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Inflammatory Bowel Disease, Pediatric
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P-565
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ISC
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ORG
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Pelvic Inflammatory Disease (PID), Acute, Pediatric
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P-260
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ISC
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ORG
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Spine, Scoliosis, Posterior Instrumentation, Pediatric
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P-1056
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ISC
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ORG
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Supraventricular Arrhythmias, Pediatric
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P-510
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ISC
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CCC
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Pain: Common Complications and Conditions
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CCC-050
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RFC
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ORG
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Degenerative Joint Disease (DJD)
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M-7030
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BHC
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LOC
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Obsessive-Compulsive and Related Disorders, Adult: Inpatient Care
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B-030-IP
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BHC
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LOC
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Obsessive-Compulsive and Related Disorders, Child or Adolescent: Inpatient Care
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B-029-IP
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BHC
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LOC
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Obsessive-Compulsive and Related Disorders: Residential Care
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B-030-RES
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|
BHC
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LOC
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Obsessive-Compulsive and Related Disorders: Partial Hospital Program
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B-030-PHP
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|
BHC
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LOC
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Obsessive-Compulsive and Related Disorders: Intensive Outpatient Program
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B-030-IOP
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|
BHC
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LOC
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Obsessive-Compulsive and Related Disorders: Acute Outpatient Care
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B-030-AOP
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Empire Customizations to MCG care guideline 23rd Edition
Effective August 1, 2019, the following MCG care guideline 23rd edition customizations will be implemented.
- Left Atrial Appendage Closure, Percutaneous (W0157) - customized to refer to SURG.00032 Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention
- Spine, Scoliosis, Posterior Instrumentation, Pediatric (W0156) - customized to refer to Musculoskeletal Program Clinical Appropriateness Guidelines, Level of Care Guidelines and Preoperative Admission Guidelines
To see a more detailed summary of customizations click on this Link.
For questions, please contact the provider service number on the back of the member's ID card. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. ATTENTION OFFICE MANAGERS AND STAFF: In the next month you will receive a request to validate your provider’s demographic and participation information. Your response is required within two weeks of receipt of the email. REMEMBER Payers, providers and patients lose when directory listings are inaccurate!
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Empire has identified an increasing trend in the billing of emergency room (ER) level 5 Evaluation and Management (E/M) codes. To help manage increasing healthcare costs, beginning August 1, 2019, Empire will initiate the post-pay review of professional ER claims billed with level 5 E/M Codes (99285 or G0384) to ensure documentation meets or exceeds the components necessary to support its billing. Professional ER claims with the highest potential for up-coding will be selected.
Empire will request documentation for identified claims, and level 5 ER professional reviews will evaluate the appropriate use of the level 5 ER code based on the AMA CPT coding manuals, and Empire guidelines. Reimbursement will be based on the ER E/M code the submitted documentation supports.
Please note, these coding reviews are not related to any prior notifications of reviews which examine the appropriate use of ERs for non-emergencies, nor do they include the examination of emergent versus non-emergent reasons patient utilize emergency room services. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Have you had more patients present with their ID card on their smartphone? We want to remind you of the ways you can access your own copy of their ID card.
In the October 2017 issue of Network Update, Empire informed you about our mobile app called Empire Anywhere that allows members to manage their benefits on their smart phones, including the option of an electronic only version of their ID cards. We want to ensure a member’s electronic only ID card meets your needs.
Based on member requests and growing trends, we anticipate that by the year 2020, nearly 50% of our Local Plan members may choose the electronic ID card option, so we urge you to start using the available retrieval tools today.
Provider options for obtaining a copy of an electronic Member ID card
- Online -- through the Availity Portal: Providers also have the option to view Empire Member ID Cards online (and print if needed) from the Availity Portal at availity.com. When conducting an Eligibility and Benefits (E&B) Inquiry -- from the E&B Results page, select the blue button titled View Member ID Card. (Currently excludes BlueCard®, Federal Employee Program® (FEP) and some health plans’ Medicare Advantage and Medicaid members.) Note: as with all E&B Inquiries on Availity, providers must have the member ID number (including the three-character prefix) and one or more search options of date of birth, first name and last name.
- Email or Fax: Members can email/fax the card from his/her phone. When members are viewing their ID Card on their phone, they will select the email or fax icon to forward their ID card.
These options are available for your patients who are members covered by our affiliated health plans in CA, CO, CT, GA, IN, KY, ME, MO, NH, NV, OH, WI, VA, and NY.
Members are still required to have a copy of their card in one format or another, whether hard copy or electronic, in order for services to be rendered. See our Quick Reference Guide for further details.
Quick Reference Guide
See our attached Electronic Member ID Cards – Quick Reference Guide for more details and information on:
- Frequently Asked Questions
- Details on provider options for obtaining a copy of an electronic Member ID card
- Sample electronic Member ID cards
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. As a result of coding updates in the claims system, the claim system edits for the policies and clinical guidelines listed below will be revised. This will result in the review of claims for certain diagnoses before processing occurs to determine whether the service meets medical necessity criteria. As a result, these coding updates may result in a not medically necessary and/or investigational determination.
Effective August 1, 2019, we will be implementing coding updates in the claims system for the following policies listed below which may result in investigational/not medically necessary determinations for certain services.
- GENE.00001 - Genetic Testing for Cancer Susceptibility
- GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
- GENE.00023 - Gene Expression Profiling of Melanomas
Effective August 1, 2019, we will be implementing coding updates in the claims system for the following clinical guidelines listed below which may result in not medically necessary determinations for certain services.
- CG-GENE-07 - BCR-ABL Mutation Analysis
- CG-GENE-09 - Genetic Testing for CHARGE Syndrome
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 medical policies, clinical guidelines and reimbursement policies*. The implementation date for each policy or guideline is noted for each section. Implementation of the new or revised medical policy, clinical guideline or reimbursement policy is effective for all claims processed on and after the specified implementation date, regardless of date of service. Previously processed claims will not be reprocessed as a result of the changes. If there is any inconsistency or conflict between the brief description provided below and the actual policy or guideline, the policy or guideline will govern.
Federal and state law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over medical policy and clinical guidelines (and medical policy takes precedence over clinical guidelines) and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that the services are rendered must be used. This document supplements any previous medical policy and clinical guideline updates that may have been issued by Empire. Please include this update with your Provider Manual for future reference.
Please note that medical policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Empire’s medical policies and clinical guidelines can be found at empireblue.com.
*Note: These updates may not apply to all ASO Accounts as some accounts may have non-standard benefits that apply.
Medical Policy Updates
Revised Medical Policies Effective 03-28-2019
(The following policies were revised to expand medical necessity indications or criteria.)
- DRUG.00053 - Carfilzomib (Kyprolis®)
- DRUG.00082 - Daratumumab (DARZALEX®)
- DRUG.00088 - Atezolizumab (Tecentriq®)
Revised Medical Policies Effective 04-24-2019
(The following policies were revised to expand medical necessity indications or criteria.)
- GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00045 - Detection and Quantification of Tumor DNA Using Next Generation Sequencing in Lymphoid Cancers
- SURG.00121 - Transcatheter Heart Valve Procedures
Archived Medical Policy Numbers Effective 04-24-2019
(The following policy numbers have been archived.)
- DRUG.00003 - Chelation Therapy (NOTE: This policy has been renumbered to MED.00127 - Chelation Therapy.)
- DRUG.00034 - Insulin Potentiation Therapy (NOTE: This policy has been renumbered to MED.00128 - Insulin Potentiation Therapy.)
Recategorized Medical Policies Effective 04-24-2019
(The following policies were renumbered and had no changes to the policy position or criteria.)
- MED.00127 - Chelation Therapy (NOTE: This policy has been renumbered, formerly DRUG.00003.)
- MED.00128 - Insulin Potentiation Therapy (NOTE: This policy has been renumbered, formerly DRUG.00034.)
Revised Medical Policies Effective 04-24-2019
(The following policies were reviewed and had no significant changes to the policy position or criteria.)
- ANC.00008 - Cosmetic and Reconstructive Services of the Head and Neck
- DME.00009 - Vacuum Assisted Wound Therapy in the Outpatient Setting
- DME.00022 - Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)
- DME.00032 - Automated External Defibrillators for Home Use
- DRUG.00076 - Blinatumomab (Blincyto®)
- DRUG.00107 - Avelumab (Bavencio®)
- DRUG.00109 - Durvalumab (Imfinzi®)
- GENE.00001 - Genetic Testing for Cancer Susceptibility
- GENE.00003 - Genetic Testing and Biochemical Markers for the Diagnosis of Alzheimer's Disease
- GENE.00009 - Gene-Based Tests for Screening, Detection and Management of Prostate Cancer
- GENE.00017 - Genetic Testing for Diagnosis and Management of Hereditary Cardiomyopathies (including arrhythmogenic right ventricular dysplasia/cardiomyopathy)
- GENE.00023 - Gene Expression Profiling of Melanomas
- GENE.00026 - Cell-Free Fetal DNA-Based Prenatal Testing
- GENE.00038 - Genetic Testing for Statin-Induced Myopathy
- LAB.00003 - In Vitro Chemosensitivity Assays and In Vitro Chemoresistance Assays
- LAB.00011 - Analysis of Proteomic Patterns
- LAB.00015 - Detection of Circulating Tumor Cells in the Blood as a Prognostic Factor for Cancer
- LAB.00025 - Topographic Genotyping
- MED.00004 - Technologies for the Evaluation of Skin Lesions (including Dermatoscopy, Epiluminescence Microscopy, Videomicroscopy, Ultrasonography)
- MED.00011 - Sensory Stimulation for Brain-Injured Individuals in Coma or Vegetative State
- MED.00024 - Adoptive Immunotherapy and Cellular Therapy
- MED.00053 - Noninvasive Measurement of Left Ventricular End Diastolic Pressure in the Outpatient Setting
- MED.00057 - MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications
- MED.00059 - Idiopathic Environmental Illness (IEI)
- MED.00077 - In-Vivo Analysis of Gastrointestinal Lesions
- MED.00087 - Imaging Techniques for Screening and Identification of Cervical Cancer
- MED.00102 - Ultrafiltration in Decompensated Heart Failure
- MED.00104 - Non-invasive Measurement of Advanced Glycation Endproducts (AGEs) in the Skin
- MED.00105 - Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema
- MED.00111 - Intracardiac Ischemia Monitoring
- MED.00112 - Autonomic Testing
- MED.00118 - Continuous Monitoring of Intraocular Pressure
- MED.00120 - Voretigene neparvovec-rzyl (Luxturna®)
- MED.00125 - Biofeedback and Neurofeedback
- OR-PR.00004 - Partial-Hand Myoelectric Prosthesis
- RAD.00001 - Computed Tomography to Detect Coronary Artery Calcification
- RAD.00038 - Use of 3-D, 4-D or 5-D Ultrasound in Maternity Care
- RAD.00040 - PET Scanning Using Gamma Cameras
- RAD.00044 - Magnetic Resonance Neurography
- RAD.00052 - Positional MRI
- RAD.00054 - MRI of the Bone Marrow
- RAD.00059 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Malignant Lesions Outside the Liver except Central Nervous System (CNS) and Spinal Cord
- SURG.00016 - Stereotactic Radiofrequency Pallidotomy
- SURG.00022 - Lung Volume Reduction Surgery
- SURG.00026 - Deep Brain, Cortical, and Cerebellar Stimulation
- SURG.00043 - Electrothermal Shrinkage of Joint Capsules, Ligaments and Tendons
- SURG.00045 - Extracorporeal Shock Wave Therapy for Orthopedic Conditions
- SURG.00053 - Unicondylar Interpositional Spacer
- SURG.00056 - Transanal Radiofrequency Treatment of Fecal Incontinence
- SURG.00061 - Presbyopia and Astigmatism-Correcting Intraocular Lenses
- SURG.00062 - Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
- SURG.00070 - Photocoagulation of Macular Drusen
- SURG.00072 - Lysis of Epidural Adhesions
- SURG.00075 - Intervertebral Stabilization Devices
- SURG.00089 - Self-Expanding Absorptive Sinus Ostial Dilation
- SURG.00096 - Surgical and Ablative Treatments for Chronic Headaches
- SURG.00107 - Prostate Saturation Biopsy
- SURG.00113 - Artificial Retinal Devices
- SURG.00124 - Carotid Sinus Baroreceptor Stimulation Devices
- SURG.00132 - Drug-Eluting Devices for Maintaining Sinus Ostial Patency
- SURG.00137 - Focused Microwave Thermotherapy for Breast Cancer
- SURG.00139 - Intraoperative Assessment of Surgical Margins During Breast-Conserving Surgery with Radiofrequency Spectroscopy or Optical Coherence Tomography
- SURG.00148 - Spectral Analysis of Prostate Tissue by Fluorescence Spectroscopy
- SURG.00149 - Percutaneous Ultrasonic Ablation of Soft Tissue
- SURG.00150 - Leadless Pacemaker
- SURG.00151 - Balloon Dilation of Eustachian Tubes
- TRANS.00011 - Pancreas Transplantation and Pancreas Kidney Transplantation
- TRANS.00013 - Small Bowel, Small Bowel/Liver, and Multivisceral Transplantation
- TRANS.00016 - Umbilical Cord Blood Progenitor Cell Collection, Storage and Transplantation
- TRANS.00025 - Laboratory Testing as an Aid in the Diagnosis of Heart Transplant Rejection
- TRANS.00028 - Hematopoietic Stem Cell Transplantation for Hodgkin Disease and non-Hodgkin Lymphoma
- TRANS.00031 - Hematopoietic Stem Cell Transplantation for Autoimmune Disease and Miscellaneous Solid Tumors
Archived Medical Policies Effective 05-09-2019
(The following policies have been archived and their content has been transferred to new Clinical UM Guidelines.)
- DRUG.00110 - Inotuzumab ozogamicin (Besponsa®) [Note: Content transferred to CG-DRUG-113 Inotuzumab ozogamicin (Besponsa®)]
- GENE.00002 - Preimplantation Genetic Diagnosis Testing [Note: Content transferred to CG-GENE-06 Preimplantation Genetic Diagnosis Testing]
- GENE.00005 BCR-ABL Mutation Analysis [Note: Content transferred to CG-GENE-07 BCR-ABL Mutation Analysis]
- GENE.00031 - Genetic Testing for PTEN Hamartoma Tumor Syndrome [Note: Content transferred to CG-GENE-08 Genetic Testing for PTEN Hamartoma Tumor Syndrome]
- GENE.00040 - Genetic Testing for CHARGE Syndrome [Note: Content transferred to CG-GENE-09 Genetic Testing for CHARGE Syndrome]
- MED.00119 - High Intensity Focused Ultrasound (HIFU) for Oncologic Indications [Note: Content transferred to CG-MED-81 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications]
- RAD.00066 - Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy [Note: Content transferred to CG-SURG-98 Prostate Multiparametric Magnetic Resonance Imaging]
- SURG.00048 - Panniculectomy and Abdominoplasty [Note: Content transferred to CG-SURG-99 Panniculectomy and Abdominoplasty]
Archived Medical Policy Effective 06-24-2019
(The following policy has been archived and its content has been transferred to a new Clinical UM Guideline.)
- SURG.00033 - Cardioverter Defibrillators [Note: Content transferred to CG-SURG-97 Cardioverter Defibrillators]
New Medical Policy Effective 05-11-2019
(The following policy is new and determined to not have significant changes.)
- SURG.00152 - Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing
New Medical Policy Effective 08-01-2019
(The following policy is new and determined to not have significant changes.)
- GENE.00050 - Gene Expression Profiling for Coronary Artery Disease [Note: Content transferred from GENE.00043 Genetic Testing of an Individual’s Genome for Inherited Diseases]
Revised Medical Policies Effective 08-01-2019
(The policies below were revised and might result in services that were previously covered but may now be found to be either not medically necessary and/or investigational.)
- GENE.00007 - Cardiac Ion Channel Genetic Testing
- GENE.00010 - Genotype Testing for Genetic Polymorphisms to Determine Drug-Metabolizer Status
- GENE.00012 - Preconception or Prenatal Genetic Testing of a Parent or Prospective Parent
- GENE.00043 - Genetic Testing of an Individual’s Genome for Inherited Diseases [Note: Content for gene expression profiling for coronary disease moved to new medial policy GENE.00050 Gene Expression Profiling for Coronary Artery Disease]
Revised Medical Policy Effective 08-17-2019
(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.00101 - Physiologic Recording of Tremor using Accelerometer(s) and Gyroscope(s)
Clinical Guideline Updates
Revised Clinical Guideline Effective 03-19-2019
(The following adopted guideline was updated with new HCPCS procedure codes.)
- CG-MED-79 – Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems
Revised Clinical Guidelines Effective 03-28-2019
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-50 - Paclitaxel, protein-bound (Abraxane®)
- CG-DRUG-96 - Ado-trastuzumab emtansine (Kadcyla®)
- CG-GENE-04 - Molecular Marker Evaluation of Thyroid Nodules
Revised Clinical Guidelines Effective 03-28-2019
(The following adopted guidelines were updated with new HCPCS procedure codes.)
- CG-DRUG-63 – Levoleucovorin Products
- CG-DRUG-78 – Antihemophilic Factor and Clotting Factors
- CG-DRUG-98 - Bendamustine Hydrochloride
Archived Clinical Guideline Numbers Effective 04-24-2019
(The following clinical guideline numbers have been archived.)
- CG-DRUG-25 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting (NOTE: This guideline has been renumbered to CG-MED-82.)
- CG-DRUG-47 - Level of Care: Specialty Pharmaceuticals (NOTE: This guideline has been renumbered to CG-MED-83.)
Recategorized Clinical Guidelines Effective 04-24-2019
(The following adopted guidelines were renumbered and had no changes to the policy position or criteria.)
- CG-MED-82 - Intravenous versus Oral Drug Administration in the Outpatient and Home Setting (NOTE: This guideline has been renumbered, formerly CG-DRUG-25.)
- CG-MED-83 - Level of Care: Specialty Pharmaceuticals (NOTE: This guideline has been renumbered, formerly CG-DRUG-47.)
Revised Clinical Guidelines Effective 04-24-2019
(The following adopted guidelines were revised to expand medical necessity indications or criteria.)
- CG-DRUG-68 - Bevacizumab (Avastin®) for Non-Ophthalmologic Indications
- CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
- CG-SURG-09 - Temporomandibular Disorders
Revised Clinical Guidelines Effective 04-24-2019
(The following adopted guidelines were reviewed and had no significant changes to the policy position or criteria.)
- CG-BEH-02 - Adaptive Behavioral Treatment for Autism Spectrum Disorder
- CG-DME-06 - Pneumatic Compression Devices for Lymphedema
- CG-DRUG-49 - Doxorubicin Hydrochloride Liposome Injection
- CG-DRUG-51 - Romidepsin (Istodax®)
- CG-DRUG-53 - Drug Dosage, Frequency, and Route of Administration
- CG-DRUG-62 - Fulvestrant (FASLODEX®)
- CG-DRUG-67 - Cetuximab (Erbitux®)
- CG-DRUG-100 - Interferon gamma-1b (Actimmune®)
- CG-DRUG-101 - Ixabepilone (Ixempra®)
- CG-DRUG-102 - Olaratumab (Lartruvo™)
- CG-GENE-02 - Analysis of KRAS Status
- CG-MED-37 - Intensive Programs for Pediatric Feeding Disorders
- CG-MED-55 - Level of Care: Advanced Radiologic Imaging
- CG-MED-69 - Inhaled Nitric Oxide
- CG-MED-70 - Wireless Capsule Endoscopy for Gastrointestinal Imaging and the Patency Capsule
- CG-REHAB-08 - Private Duty Nursing in the Home Setting
- CG-SURG-74 - Total Ankle Replacement
- CG-SURG-76 - Carotid, Vertebral and Intracranial Artery Stent Placement with or without Angioplasty
- CG-SURG-78 - Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
- CG-SURG-80 - Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
- CG-TRANS-02 - Kidney Transplantation
Adopted Clinical Guidelines Effective 05-09-2019
(The following guidelines were previously medical policies and have been adopted and have no significant changes.)
- CG-DRUG-113 - Inotuzumab ozogamicin (Besponsa®) [Note: Content moved from DRUG.00110 Inotuzumab ozogamicin (Besponsa®)]
- CG-GENE-06 - Preimplantation Genetic Diagnosis Testing [Note: Content moved from GENE.00002 Preimplantation Genetic Diagnosis Testing]
- CG-GENE-07 - BCR-ABL Mutation Analysis [Note: Content moved from GENE.00005 BCR-ABL Mutation Analysis]
- CG-GENE-08 - Genetic Testing for PTEN Hamartoma Tumor Syndrome [Note: Content moved from GENE.00031 Genetic Testing for PTEN Hamartoma Tumor Syndrome]
- CG-GENE-09 - Genetic Testing for CHARGE Syndrome [Note: Content moved from GENE.00040 Genetic Testing for CHARGE Syndrome]
- CG-MED-81 - High Intensity Focused Ultrasound (HIFU) for Oncologic Indications [Note: Content moved from MED.00119 High Intensity Focused Ultrasound (HIFU) for Oncologic Indications]
- CG-SURG-98 - Prostate Multiparametric Magnetic Resonance Imaging [Note: Content moved from RAD.00066 Multiparametric Magnetic Resonance Fusion Imaging Targeted Prostate Biopsy]
- CG-SURG-99 - Panniculectomy and Abdominoplasty [Note: Content moved from SURG.00048 Panniculectomy and Abdominoplasty]
Adopted Clinical Guideline Effective 06-24-2019
(The following guideline was previously a medical policy and has been adopted and has no significant changes.)
- CG-SURG-97 - Cardioverter Defibrillators [Note: Content moved from SURG.00033 Cardioverter Defibrillators]
Revised Clinical Guidelines Effective 08-01-2019
(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-DME-44 - Electric Tumor Treatment Field (TTF)
- CG-GENE-01 - Janus Kinase 2, CALR and MPL Gene Mutation Assays
- CG-MED-72 - Hyperthermia for Cancer Therapy
Revised Clinical Guideline Effective 08-17-2019
(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-09 - Temporomandibular Disorders
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. Beginning with dates of service on or after April 28, 2019, Empire policy language will be updated to allow the lower level definitive code drug testing of 1-7 drug class(es) (G0480) on the same day as presumptive services. Additionally, the definitive drug testing related coding section was expanded for clarification.
For more information about this new policy, visit the Reimbursement Policy page at empireblue.com/provider. Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. The following clinical criteria will be effective August 1, 2019.
Agents for Hereditary Angioedema ING-CC-0034
Effective for dates of service on and after August 1, 2019, the following specialty pharmacy codes from new or current clinical criteria will be included in our existing specialty pharmacy medical step therapy review process. Haegarda® and Takhzyro™ will be the preferred prophylactic agents over Cinryze®.
Please note, inclusion of NDC code on your claim will shorten the claim processing time of drugs billed with a Not Otherwise Classified (NOC) code.
Learn more about clinical criteria information.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code
|
NDC Code
|
|
ING-CC-0034
|
Preferred Agent
|
Haegarda®
|
J0599
|
63833-0828-02
63833-0829-02
|
|
ING-CC-0034
|
Preferred Agent
|
Takhzyro™
|
J3490, J3590, C9399
|
47783-0644-01
|
|
ING-CC-0034
|
Non-Preferred Agent
|
Cinryze®
|
J0598
|
42227-0081-05
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. For more information on copayment/coinsurance requirements and their applicable drug classes, drug lists and changes, prior authorization criteria, procedures for generic substitution, therapeutic interchange, step therapy or other management methods subject to prescribing decisions, and any other requirements, restrictions, or limitations that apply to using certain drugs, visit empireblue.com/pharmacyinformation. The commercial and marketplace drug lists are posted to the web site quarterly (the first of the month for January, April, July and October).
To locate Marketplace scroll down to “Select Drug Lists.” This drug list is also reviewed and updated regularly as needed.
FEP Pharmacy updates and other pharmacy related information may be accessed at www.fepblue.org > Pharmacy Benefits.Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. In the February edition of Provider News, we shared that the following clinical criteria will be effective May 1, 2019. We will begin the medical step therapy review process for non-oncology uses of these drugs at this time. We will notify you when we begin the medical step therapy review process for oncology indications.
Colony Stimulating Factor Agents ING-CC-0002
Effective for dates of service on and after May 1, 2019, the following specialty pharmacy codes from new or current criteria will be included in our existing specialty pharmacy medical step therapy review process. Zarxio® will be the preferred short-acting colony stimulating factor (CSF) agent over Neupogen®, Granix®, and Nivestym™®.
[BRAND]’s prior authorization clinical review of these specialty pharmacy drugs will be managed by AIM Specialty Health® (AIM), a separate company.
Additional information regarding biosimilar drugs can be found by viewing the attached reference document, “Biosimilar Drugs – What are they?”.
Learn more about clinical criteria information.
|
Clinical Criteria
|
Status
|
Drug
|
HCPCS or CPT Code
|
NDC Code
|
|
ING-CC-0002
|
Preferred Agent
|
Zarxio®
|
Q5101
|
61314-0304-01
61314-0304-10
61314-0312-01
61314-0312-10
61314-0318-01
61314-0318-10
61314-0326-01
61314-0326-10
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Neupogen®
|
J1442
|
55513-0530-01
55513-0530-10
55513-0546-01
55513-0546-10
55513-0924-01
55513-0924-10
55513-0924-91
55513-0209-01
55513-0209-10
55513-0209-91
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Granix®
|
J1447
|
63459-0910-11
63459-0910-12
63459-0910-15
63459-0910-17
63459-0910-36
63459-0912-11
63459-0912-12
63459-0912-15
63459-0912-17
63459-0912-36
|
|
ING-CC-0002
|
Non-Preferred Agent
|
Nivestym™
|
Q5110
|
00069-0291-10
00069-0291-01
00069-0292-01
00069-0292-10
|
Beginning January 1, 2024, Empire became Anthem. This article, published under the former brand, now applies to Anthem. On August 17, 2018, October 9, 2018, and November 16, 2018, the pharmacy and therapeutic (P&T) committee approved Clinical Criteria applicable to the medical drug benefit for Empire BlueCross BlueShield HealthPlus (Empire). These policies were developed, revised or reviewed to support clinical coding edits.
The Clinical Criteria is publicly available on the Empire provider website, and the effective dates are reflected in the Clinical Criteria updates notification. Visit the Clinical Criteria website to search for specific policies.
Email for questions or additional information. 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. Medicare Advantage plans under Empire BlueCross BlueShield follow original Medicare guidelines and billing requirements for partial hospitalization services. CMS regulations (42 CFR 410.43(c)(1)) state that partial hospitalization programs (PHPs) are intended for members who require a minimum of 20 hours per week of therapeutic services as evidenced in their plan of care. All partial hospitalization services require prior authorization. Read more.
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